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The  Surgical  Diseases  of  the 
Genito-Urinary  Tract 

VENEREAL  AND  SEXUAL  DISEASES 


A    TEXT-BOOK    FOR  STUDENTS    AND 
PRACTITIONERS 


G.  FRANK  LYDSTON,  M.D. 


Professor  of  the  Surgical  Diseases  of  the  Genito-Urinary   Organs  and  Syphilology   in  the  MEmcAi,  De- 
partment OF  the  State  University  of  Illinois  (the  Chicago  College  of  Physicians  and  Surgeons^  : 
Professor  of  Criminal  Anthropology  in  the   Kent  College  op   Law;    Scrgeon-in-Chief  to 
the  Genito-Urinary   Department  of  the  West-side   Dispensary  :    Late  Major  and 
Surgeon,  U.  S.  V.;  Fellow  of  the   Chicago  Academy  of  Medicine:  Fellow 
OF  THE  American  Academy  of  Political  and  Social  Science  ;  Dele- 
gate from  the  United  States  to  the  International  Con- 
gress for  the  Prevention  of  Syphilis  and  the 
Venereal  Diseases   held  at  Brussels, 
Belgium,  September  o,  1S99  ;  etc. 


Illustrated  witb  235  Ettgravittds 


Philadelphia,  New  York,  Chicago 
THE  F.  A.  DAVIS  COMPANY,  PUBLISHERS 

1899 


COPYRIGHT.  1S99, 

BY 

THE  F.  A.  DAVIS  COMPANY. 
I  Registered  at  St.itioners'  Hall.  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A. : 

The  Medical  Bulletin  Printing-house, 

1914-16  Cherry  Street. 


TO 

FESSENDEN  N.  OTIS, 

In  Token  of  Appreciatiox  of  His  OEroixAL  Research  and 

Practical    Clinical    Observations,     avhich    Have 

Been  the    Basis    of    the  Best  Work  that 

Genito-Urinary    Surgery  Has  Thus 

Far  Accomplished  in  America, 

AND  AS  A 

Testimonial  of  Personal  Gratitude  and  Esteem  from  His 

Old-Time   Hospital  Interne,   this   Volume   is 

Affectionately    Inscribed   by 

THE  AUTHOR. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/surgicaldiseasesOOIyds 


PREFACE. 


In  view  of  the  cordial  manner  in  which  my  various  contributions  to 
the  subjects  embraced  in  this  volume  have  been  received  by  the  profession^ 
I  have  felt  that  the  publication  of  a  more  comprehensive  treatise  hardly 
requires  either  apology  or  explanation.  I  have  embraced  the  opportunity 
herein  afforded  me  for  airing  a  few  heresies  of  my  own,  in  juxtaposition 
with  as  much  of  the  accepted  and  standard  teachings  as  it  is  practicable  to 
present  in  a  work  chiefly  designed  for  the  student  and  general  practitioner 
rather  than  the  specialist;  but  this  may  be  pardoned.  Ko  attempt  has  been 
made  to  cover  the  literature  of  the  various  subjects  comprised  in  this  vol- 
ume. The  endeavor  has  been  to  give  a  practical  survey  of  the  field  of  genito- 
urinary and  venereal  diseases,  following  as  closely  as  practicable  the  plan 
of  my  course  of  lectures  on  the  subject  delivered  in  the  Medical  Depart- 
ment of  the  University  of  Illinois. 


aC^^^^L&T,*^ 


Reliance  Building, 
Chicago,  September  1,  1899. 


(V) 


CONTE>s"TS. 


PAET  I. 

General  PEiisrciPLES  of  Genito-Ukinaey,  Sexual,  and  Venereal 
Pathology  and  Therapeutics. 

CHAPTER  I.  PAGE 

Genito-Urinaiy  and   Sexual  Hygiene 1 

CHAPTER  11. 
Urinalysis  in  its  Surgical  Relations 10 

CHAPTER  III. 
Hematuria    34 

CHAPTER  IV. 
The  Bacteriologic  Relations  of  Genito-Urinary  Infections  and  Secondary  Infec- 
tions and  Toxemias  of  Urinary  Origin 46 

CHAPTER  V. 
General   Morbid  Phenomena  Incidental   to  the   Surgery   of  the   Genito-Urinary 

Organs 54 


PAET  II. 

NON- VENEREAL    DISEASES    OF    THE    PeNIS. 

CHAPTER  VI. 
Anatomy    and    Physiology,    Anomalous    Formations,    Traumatisms,    Acute    and 

Chronic  Inflammations,  Neoplasms,  and  Amputation  of  the  Penis 69 

CHAPTER  VII. 
Diseases  of  the  Skin  and  Quasimucous  Mambrane  of  the  Penis 80 


PAET  III. 

Diseases  of  the  Urethra  and  Gonorrhea. 

CHAPTER  VIII. 

Diseases    of    the    Male    Urethra:     Anatomy    and    Physiology;      Traumatisms; 

Foreign  Bodies  and  Tumors  of  the  Urethra 94 

CHAPTER  IX. 

Urethritis  and  Gonorrhea ■. 116 

(Yii) 


Vni  CONTENTS. 

CHAPTER  X.  PAGE 

Gonorrhea   in  the  Female 163 

CHAPTER  XL 
Stricture  of  the  Urethra 172 


PAET  IV. 

Chanckoid  axd  Bubo  ajs^d  their  Complications. 

CHAPTER  XII. 
Chancroid   265 

CHAPTER  XIII. 
Venereal  Adenitis,  or  Bubo 308 


PART  Y. 

Syphilis. 

CHAPTER  XIY. 
Syphilis 332 

CHAPTER  XV. 

Methods  of  Acquiring  Syphilis — Varieties  and  Treatment  of  Chancre — Primary 

Syphilitic  Adenopathy   363 

CHAPTER  XVI. 
General   Infection   of   Syphilis 376 

CHAPTER  XVII. 
Early  Brain  and  Xerve  Syphilis 398 

CHAPTER  XVIII. 
The  Period  of  Sequels,  or  So-Called  Tertiary  Syphilis 417 

CHAPTER  XIX. 
Congenital  Syphilis — Acquired  Syphilis  in  Children 4.55 

CHAPTER  XX. 
Treatment   of   Syphilis 469 


PAET  YI. 

Diseases  Affecting  Sexual  Physiology. 

CHAPTER  XXI. 

Aberrant  and  Imperfect  Differentiation  of  Sex 515 


CONTEN'TS.  IX 

CHAPTER  XXII.  PAGE 

Diseases  of  the  Sexual  Function  and  Instinct 524 

CHAPTER  XXIII. 
Aberrations  of  the  Sexual  Instinct 529 

CHAPTER  XXIV. 
Satyriasis,    Xymphomania,    Masturbation,    Sexual    Excess,    and    Unphysiologic 

Coitus    544 

CHAPTER  XXV. 
Impotence  and  Sterility 568 

CHAPTER  XXVI. 
Spermatorrhea     602 


PAET  VII. 
Diseases  of  the  Peostate  and  Seminal  Vesicles. 

CHAPTER  XXVII. 
Diseases  of  the  Prostate 624 

CHAPTER  XXVIII. 

Chronic  Prostatic  Inflammation  and  Suppuration 663 

CHAPTER  XXIX. 
Tuberculosis  of  the  Prostate.    Cancer  of  the  Prostate.    Calculus  of  the  Prostate .  .     675 

CHAPTER  XXX. 
Hypertrophy  of  the  Prostate 686 

CHAPTER  XXXI. 
Diseases  of  the  Seminal  Vesicles 728 


PART  VIII. 
Diseases  of  the  Urinary  Bladder. 

CHAPTER  XXXII. 
Diseases  of  the  Urinary  Bladder 732 

CHAPTER  XXXIII. 
Neoplasms  of  the  Bladder  and  Vesical  Tuberculosis 757 

CHAPTER  XXXIV. 
Urinary  Calculus 776 

CHAPTER  XXXV. 
Neuroses  of  the  Bladder 830 


X  -CONTENTS. 

PAET  IX. 

Surgical  Affections  of  the  Kidney  and  Ureter. 

CHAPTER  XXXVI.  page 

Surgical  Affections  of  the  Kidney 842 

CHAPTER  XXXVII. 
Surgical  Aflfections  of  the  Kidney  (Continued) 878 

CHAPTER  XXXVIII. 
Diseases  of  the  Ureter 907 


PAET  X. 

Diseases  of  the  Testis  and  Spermatic  Cord. 

CHAPTER  XXXIX. 
Diseases  of  the  Scrotum,  Testis,  and  Spermatic  Cord 916 

CHAPTER  XL. 
Hydrocele    928 

•   CHAPTER  XLI. 
Inflammatory  Affections  of  the  Testis 941 

CHAPTER  XLII. 
Neoplasms  of  the  Testis 969 

CHAPTER  XLIII. 
Varicocele 985 


Appendix    1000 

Index    1003 


LIST  OF  ILLUSTEATIONS. 


FIG.  PAGE. 

1.  Ammonium-urate  crystals 17 

2.  iJrie-acid  crystals 19 

3.  Calcium-oxalate  crystals   20 

4.  Triple-phosjjhate  crystals    21 

5.  Morning  urine  in  a  spermatorrheic 32 

6.  Section  of  the  penis  at  about  its  middle 69 

7.  Buck's   fascia 72 

8.  "Osseous"  degeneration  of  the  penis 75 

9.  Penile  epithelioma.     Vegetating  form 76 

10.  Operation  for  phimosis 82 

11.  Venereal  vegetations    92 

12.  Simple   penile  papillomata 93 

13.  The  fossa  navicularis 94 

14.  Showing  lacuna  magna 95 

15.  Diagrammatic  section  of  perineum,  showing  arrangement  of  the  triangular 

ligament 96 

16.  Dissection  of  perineum,  showing  relation  of  bulb  of  urethra  to  the  triangu- 

lar ligament   97 

17.  Dissection   of   perineum,    showing    deeper   parts    in   their   relation   to   the 

urethra  97 

18.  Normal  curve  of  urethra 98 

19.  Bell's  curve,  showing  relation  of  English,  American,  and  Benique  sounds 

to  it,  and  comparative  length  of  beaks 98 

20.  Case  of.  hypospadias    (pseudohermaphroditism) 100 

21.  Case  of  hypospadias  with  marked  feminine  physique 101 

22.  Operation  for  hypospadias 102 

23.  Case  of  simple  epispadias 1 03 

24.  Dolbeau's   operation 104 

25.  Dolbeau's  operation,  flaps  in  position 105 

26.  Formation  of  glans  urethra 106 

27.  Formation  of  penile  urethra 106 

28.  Flaps  sutured  in  position 107 

29.  Formation  of  preputial  graft 107 

30.  Preputial  graft 108 

31.  Closure  of  posterior  urethral  defect 108 

32.  Closure  of  posterior  urethral  defect 109 

33.  Alligator  urethral  forceps 112 

34.  Adenomata  of  the  urethra 113 

35.  Adenoma   of   the   urethra 114 

36.  Gonococci  in  lu'ethral  pus 123 

37.  Periurethral   phlegmon 130 

38.  Lydston's  urethral  irrigator 137 

39.  Proper  form  of  urethral  syringe 145 

40.  Chronic  granular  urethritis 151 

41.  Guyon's  bulbous  "bougie  exploratrice" 153 

42.  Lamp  for  direct  electric  illumination  of  the  urethra 153 

43.  Endoscope    154 

44.  Author's  endoscopic  tubes 154 

45.  Cupped  sound  for  urethral  medication 155 

46.  Brown's   urethral   speculum 156 

47.  Author's  syringe  for   deep  injection 157 

48.  Oberlaender's  dilator   (straight) 159 

49.  Oberlaender's  dilator  with  deep  curve 159 

50.  Gonorrheal  inflammation  of  the  left  vulvo-vaginal  gland 169 

51.  Showing  the  manner  in  which  urethral  coarctation  and  spasm  oppose  the 

entrance  and  withdrawal  of  a  bulbous  bougie 174 

52.  Linear  stricture 184 

53.  Bridle  stricture 185 

54.  Annular  stricture 186 

(xi) 


Xll  LIST    OF    ILLUSTEAT10X5. 

FIG.  PAGE. 

5.5.  Tortuous  multiple  stricture 187 

56.  Multiple  stricture,  penile  and  deep,  showing  varying  caliber 188 

57.  Casts  of  alleged  normal  lu-ethras,  showing  points  of  contraction 196 

58.  Dilation  and  trabeculation  of  prostatic  urethra,  secondary  to  close  bulbo- 

membranous  stricture 198 

59.  Showing    extreme    dilation    of   proximal    side    of    genito-iu'iuary    tract    iu 

stricture  of  long  standing 200 

60.  Otis's  urethrometer  . 206 

61.  ileatotome     207 

62.  Otis   exploring   bulbs 209 

63.  French  scale  for  measuring  urethral  instruments 219 

64.  Dlive-tipped   soft  bougie 225 

65.  Soft   straight   catheters 225 

66.  Screw-tipped  guides 225 

67.  Bank's  whalebone  bougies 226 

68.  Correct  curve  for  instruments 226 

69.  Author's  urethral  sounds 227 

70.  Firsi  position  in  introducing  a  sound 231 

71.  Second  position  in  introducmg  a  sound 232 

72.  Third   position 233 

73.  Fourth   and  final   position 234 

74.  False  passage  in   stricture 235 

75.  Maisonneuve's   urethrotome 239 

76.  Tne  Otis  dilating  urethrotome 240 

77.  Condition  of  urethra  fifteen  years  after  operation  of  dilating  urethrotomy.  .  243 

78.  Gouley's  catheter  staff  and  guide 244 

79.  Filiform    bougies 245 

80.  Tunneled    sound 245 

81.  Deep  urethrotomy  246 

82.  Author's  perineal  drainage-tube 247 

83.  Shirted  cannula 248 

84.  Multiple  urinary  fistulas  from  deep  stricture 258 

85.  Szymanowski's  urethroplasty  for  penile  urinary  fistula 259 

86.  Szymanowski's  urethroplasty  for  penile  urinary  fistula 259 

S7.  Szymanowski's  urethroplasty  for  penile  urinary  fistula 259 

88.  Szymanowski's  urethroplasty  for  penile  urinary  fistula 259 

89.  Szymanowski  s  operation  for  large  penile  fistula 260 

90.  Xelaton's  operation  for  penile  fistula 261 

91.  Xelaton's  operation  for  penile  fistula 262 

92.  Clark's  operation  for  penile  fistula:    first  step 262 

93.  Clark  s  operation  for  penile  fistula :    second  st«p 263 

93ff.  Section  of  chancroid  showing  Ducrey-Unna  streptobacillus  in  the  tissues.  .  266 

94.  Multiple  chancroid  in  the  female 280 

95.  Multiple  chancroids  in  the  male 282 

96.  Chronic  chancroid  of  right  labia 284 

97.  Extensive   destruction   of  the  genitals,   permeum,   and   ischio-rectal   fossas 

from  chancroid  in  an  old  syphilitic 285 

98.  Double  chancroidic  bubo  after  spontaneous  evacuation 311 

99.  Phagedenic  bubo 316 

100.  Case  of  hereditary  syphilis  diagnosed  as  and  treated  for  leprosy 333 

101.  Plantar  leprosy,  resembling  syphilis 334 

102.  Mixed  type   of  leprosy  simulating  syphflis 335 

103.  Chancre  of  upper  lip.* " 366 

1Q4.  Hard  chancre  in  the  fossa  glandis 368 

105.  Papular  syphilide 385 

106.  Papulo-squamous   syphilide    386 

107.  Pustulo-ulcerous  syphilide 387 

108.  Ulcerating  gumma    395 

109.  Ulcerous  late  syphilide 419 

110.  Squamous  syphilide — so-called  syphilitic  psoriasis — of  palms 430 

111.  Early  scjuamous  syphilide — so-called  syphilitic  psoriasis — of  palms 431 

112.  Early   circinate   syphilide 434 

113.  Circinate  syphilide    435 

114.  Ulcerous  late  syphilide 436 

115.  Secondary   circinate  syphilide 437 


LIST    OF    ILLUSTEATIO>N^S.  Xlll 

FIG.  PAGE. 

116.  Dactylitis  syphilitica   449 

117.  Dactylitis  syphilitica  with  absorption  of  bone 4.50 

118.  Showing  cranial  hyperostoses  from  tertiary  syphilis 4,52 

119.  Showing  osteoporosis  and  carious  destruction  of  frontal  region  from  ter- 

tiary syphilis    4.53 

120.  Aberrant  psychosexual  differentiation  with  imperfect  physical  differentia- 

tion      516 

121.  Pseudohermaphroditism     518 

122.  Aberrant  genitosexual  differentiation   (hypospadiac) .520 

123.  Pseudohermaphroditism     ,521 

124.  Author's  insulated  prostatic  electrode 592 

125.  Microscopic  appearance  of  normal  human  semen 607 

126.  Spermuria    611 

127.  Conventional  illustration  of  the  anatomic  relations  of  the  parts  about  the 

base  of  the  bladder 625 

128.  Showing  the  internal  anatomic  relations  of  the  bladder,  urethra,  and  pros- 

tate     626 

129.  Midsection  of  prostatic  urethra 629 

130.  Prostato-vesical  calculus   684 

.131.  An  example  of  greatly-enlarged  prostate,  mainly  due  to  fibrous  tumors.  . .  .  693 

132.  Pedimculated  '"middle  lobe"'  obstructing  catheter 694 

133.  Enlargement  of  "middle  lobe"' 695 

134.  Adenomatous  tumor  from  left  lobe  of  prostate 696 

135.  Enlargement  of  the   lateral  lobes 697 

136.  Hypertrophy,  fasciculation,  and  sacculation  of  vesical  walls 700 

137.  Small   phosphatic    calculi 704 

138.  Exploring  sound  for  diagiiosing  condition  of  vesical  neck 706 

139-     Olive-tipped  flexible  catheter 708 

140.  ■Jacc{ue"s  soft  catheter 708 

141.  The  catheter  coude 709 

142.  Metallic  catheter  with  prostatic  curve 709 

143.  Catheter  coiide  with  prostatic  curve 710 

144.  Routes   for  vesical  j^uncture 712 

145.  Hunter  McGuire's  suprapubic-fistula   stem 721 

146.  Rongeur  forceps  for  prostatectomy  and  similar  intravesical  work 721 

147.  Saw-tooth  scissors  for  intravesical  work 722 

148.  Author's  perineal  drainage-tube 723 

149.  Bottini-Freudenberg  electroprostatome 727 

1,50.     Method  of  suturing  bladder 736 

151.  Wood's  method.     Outline  of  flaps 738 

152.  The  same  after  insertion  of  sutures 738 

153.  Simple  papilloma  of  the  bladder 757 

154.  Vesical  fibropapilloma    758 

155.  Histology  of  filaments  of  papilloma  of  the  bladder 759 

1.56.     Myxosarcoma    761 

157.  Vesical  epithelioma    763 

158.  Carcinoma   of   bladder 764 

159.  Bladder  containing  medullary  cancer  complicated  by  two  calculi 765 

160.  Nitze-Leiter  cystoscope   765 

161.  Sacculation   of   bladder 769 

162.  Sacculation  of  bladder,  showing  sac  cut  open 769 

163.  Principal  varieties  of  urinary  calculi 781 

164.  Calculus  formed  around  a  hair-pin,  the  ends  of  which  ai-e  visible 782 

165.  Handle  of  a  tooth-brush,  covered  with  calcareous  deposit,  found  in  a  young 

girl's  bladder    783 

166.  Ovoid  calculus  formed  around  a  bean 784 

167.  Cluster-calculus  formed  around  a  head  of  wheat 785 

168.  Thompson's  searcher  for  stone 786 

169.  Sounding  for  stone  above  pubes 787 

170.  Sounding  for  stone  in  the  has-fond 787 

171.  Sounding  for  encysted  calculus 788 

172.  Modified  Bigelow'  lithotrite 795 

173.  Clover's  evacuating  apparatus  and  tubes 795 

.  174.     English  method  of  seizing  the  stone  in  lithotrity 796 

175.     French  method  of  seizing  the  stone  in  lithotrity 798 


xiv  LIST    OF    ILLUSTEATIOXS. 

FIG.  PAGE. 

176.  Chismore's   lithotrite 802 

177.  Chismore's  percussor  for  fracturing  calc-uli 803 

178.  Chismore's  washing  bottle  and  tube 803 

179.  Clover's   crutch    811 

180.  Position  of  patient  and  line  of  incision  in  lateral  lithotomy 812 

181.  Lithotomy-staff    813 

182.  Probe-pointed   straight  lithotomy-knife 813 

183.  Probe-pointed  curA'ed  lithotomy-scalpel 813 

184.  Conventional  diagram  of  the  perineum  and  the  incisions  in  lateral  lithot- 

omy    814 

185.  Lateral  lithotomy  with  a  curved  staff 815 

186.  The  bony  pelvis  m  its  relations  to  perineal  lithotomy 816 

187.  Incision  in  the  prostate  in  lateral  lithotomy 817 

188.  Broad-grooved  lithotomy-director  817 

189.  Combined  lithotomy-scoop  and  lithotomy-director 818 

190.  Lithotomy-forceps:    double  cuiTcd 818 

191.  Lithotomy-forceps:     single  curved 819 

192.  Irregular  calculi  removed  by  suprapubic  section 828 

193.  Single  median  kidney  lying  below  bifurcation  of  the  aorta 843 

194.  Horseshoe  kidney   844. 

195.  Renal  calculus  removed  in  the  author's  case  of  hepato-nephrolithotomy .  . .  .  854 

196.  Calculus  imbedded  in  lower  portion  of  renal  pelvis 855 

197.  Enormous  segmented  renal  calculus,  natural  size 857 

198.  Enormous  renal  calculus,  reduced:    segments  separated,  showing  facets.  . .  .  858 

199.  Calculous  pyelonephritis,  with  destruction  of  renal  tissue 862 

200.  Histology  of  acute  interstitial  nephritis  with  disseminated  abscesses 876 

201.  Hydronephrotic  kidney  without  much  enlargement 879 

202.  Tuberculous  pyelonephritis 886 

203.  Harris's  device  for  collecting  urine  from  the  ureters  separately 889 

204.  Harris's  device  for  collecting  urine  from  the  ureters  separately 890 

204o.  Harris's  device  for  collecting  urine  from  the  ureters  separately 890 

205.  Van  Hook's  method  of  anastomosis  of  the  divided  ureter 910 

206.  The  Kelly  method  of  exploring  the  ureters  in  the  female 913 

207.  Ureteral   catheter  in  position 914 

208.  Dissection  of  testis 917 

209.  Elephantiasis   scroti    921 

210.  Hematocele  of  the  tunica  vaginalis 925 

211.  Vertical  section  of  simple  hydrocele 929 

212.  Double  hydrocele  of  tunica  vaginalis 930 

213.  Encysted  hydrocele  of  the  testis 931 

214.  Tapping  a  hydrocele  932 

215.  Hydrocele  complicated  by  hernia 935 

216.  Encysted  hydrocele  of  cord 939 

217.  Benign  fungus  of  testis 944 

218.  Acute  epididymitis   953 

219.  Strapping  the  testis 964 

220.  Gumma  of  testis  surrounded  by  sclerosis 971 

221.  Disseminated  tuberculosis  of  the  body  of  the  testis 974 

222.  Tuberculosis   of  the   epididymis 975 

223.  Cancer  of  right  testis " 978 

224.  Encephaloid  of  testis 979 

225.  Section  of  cancer  of  testis,  showing  fibrous  stroma  and  alveoli  filled  with 

epithelial   cells 980 

226.  Monocystic  testis 981 

227.  Multicvstic  degeneration  of  testis.  . 982 

228.  Enormous  pendulous  scrotum  from  varicocele 987 

229.  Dissection  of  varicocele 988 

230.  Eeverdin  needle  for  varicocele 994 

231.  Large  varicocele,  seven  years  after  ablation  of  scrotum,  showing  recurrence.  996 

232.  Ablation  of  the  scrotum  with  Horteloup's  clamp 997 

233.  Henry's  clamp  for  scrotal  resection 998 


PART  I. 


GENEEAL  PEINCIPLES   OF  GENITO-URIKARY,   SEXUAL, 

AND  VENEEEAL  PATHOLOGY  AND 

THEEAPEUTICS. 


CHAPTEE  I. 

Genito-Urinaey  and  Sexual  Hygiexe. 

As  a  preliminary  to  tlie  special  study  of  genito-urinary  and  sexual 
diseases,  the  consideration  of  certain  basic  principles  bearing  upon  their 
pathology,  symptomatology,  and  treatment  is  of  the  greatest  importance. 
Success  or  failure  in  this  department  of  medical  and  surgical  science  is 
often  determined  by  the  degTee  of  intelligence  displayed  by  the  surgeon 
in  the  comprehension  and  application  of  these  principles.  In  a  general 
way^  what  will  be  said  upon  this  topic  applies  to  both  sexes.  Any  qualifica- 
tion necessitated  by  certain  anatomic  and  physiologic  differences  in  the  male 
and  female  sexual  organs  will  not  interfere  with  the  clinical  application  of 
the  various  principles  involved  from  a  general  stand-point. 

The  first  topic  for  consideration  in  natural  order  is  the  hygiene  of  the 
organs  involved  in  the  performance  of  the  urinary  and  sexual  functions. 
The  most  important  point,  especially  in  the  male,  is  the  state  of  the  urinary 
secretion. 

Normal  urine  is  more  or  less  acid,  the  physiologic  degree  of  acidity 
being  difficult  to  determine.  It  varies  greatly  with  the  individual  and  under 
different  conditions.  Much  depends  upon  the  diet,  the  amount  of  physical 
exercise  taken,  and  the  state  of  the  genito-urinary  organs.  Even  normally- 
acid  urine  is  more  or  less  irritating  to  the  mucous  membrane  in  all  acute 
inflammatory  affections  of  the  genito-urinary  apparatus,  irritation  increas- 
ing pari  passu  with  acidity.  It  is  the  correction  of  acidity,  therefore,  that 
chiefly  demands  attention.  In  every  case  of  genito-urinary  disease,  in- 
volving irritation  or  inflammation  of  the  mucous  membrane,  the  first  indi- 
cation is  to  neutralize  acidity  of  the  urine,  even  to  make  it  slightly  alkaline, 
if  possible,  by  internal  medication,  regulation  of  diet,  and  attention  to 
vicarious  elimination  of  the  products  of  retrograde  tissue-metamorphosis. 
Neutral  or  faintly-alkaline  urine  is  relatively  bland,  and  much  less  irritating 
to  the  inflamed  miTcous  membrane  than  the  normal  secretion.  A  peculiar 
fact  bearing  upon  the  irritating  properties  of  the  urine  in  inflammations 

(1) 


2  GEXITO-UEIXAEY    AXD    SEXUAL    HYGIENE. 

of  the  geuito-urinary  tract  is  that,  even  in  certain  clironic  cases  of  cystitis 
in  which  the  voided  urine  is  strongly  ammoniacal,  alkaline  remedies  are 
beneficial.  The  acid  urine,  as  it  trickles  down  from  the  renal  cortex,  irri- 
tates the  mucous  membrane  of  the  renal  pelvis  and  ureter;  the  excessive 
secretion  of  mucus  thereby  induced  enters  the  bladder  and  produces  fer- 
mentation of  the  vesical  urine,  resulting  in  ammoniacal  decomposition. 
Thus,  the  primary  source  of  the  irritation  may  be  acid  urine,  though  the 
fluid  as  voided  from  the  bladder  may  be  distinctly  alkaline. 

Eemedies  that  lessen  acidity  are  likely  to  allay  the  irritation  and  inflam- 
mation. There  are  various  drugs  that  neutralize  urinary  acidity,  the  best 
of  these  being  the  citrate  and  acetate  of  potassium.  These  combinations  of 
alkaline  salts  Avith  vegetable  acids  are  especially  useful  in  surgical  diseases 
of  the  genito-urinary  organs.  They  should  be  given  in  large  and  frequent 
doses.  They  are  usually  given  in  doses  that  are  much  too  small  to  be  serv- 
iceable. 

Pure  water  is  equal  if  not  superior  to  any  of  the  various  drugs  recom- 
mended as  diuretics  and  urinary  diluents.  Various  mineral  waters — good, 
bad,  and  indifferent — are  highly  extolled  for  their  action  in  urinary  affec- 
tions, but,  while  many  of  them  doubtless  are  valuable,  they  are  all  expensive 
and  in  no  wise  superior  to  distilled  water  taken  in  large  quantity.  When 
the  element  of  faith  in  simple  water  is  lacking,  some  natural  mineral  water 
with  a  high-sounding  name  is  likely  to  inspire  the  patient  with  confidence. 
Under  these  circumstances  he  will  probably  be  willing  to  take  enough  water 
to  be  beneficial.  Certain  of  the  manufactured  mineral  waters  are  valuable. 
Those  containing  lithia  in  considerable  amount  are  among  the  best  of  these. ^ 

The  urine  is  often  excessively  irritating  because  of  its  admixture  with 
bacteria  and  their  products.  Bacteriuria,  as  will  be  seen  in  the  chapter  on 
urinary  bacteriology,  is  a  very  important  factor  in  genito-urinary  pathology. 
Even  in  cases  where  irritation  is  obviously  due  to  ammoniacal  urine, 
bacterial  evolution  is  the  fons  origo  of  the  existing  pathologic  condition. 
It  will  be  seen,  therefore,  that  urinary  antisepsis  is  a  desideratum  in  such 
eases.  Urinary  antisepsis  may  be  accomplished  in  two  ways,  viz.:  by 
remedies  administered  per  orem  and  by  irrigations  of  the  bladder  with  anti- 
septic solutions.  The  most  efficient  urinary  antiseptics  for  internal  adminis- 
tration-are, in  the  order  of  their  efficiency,  oil  of  eucalyptus,  cystogen,  boric 
acid,  salol,  and  guaiacol.  The  best  combination  is,  in  the  author's  opinion, 
the  oil  of  eucalj'ptus  and  salol,  in  10-minim  and  lO-grain  doses,  respectively. 
This  is  best  administered  in  capsule.  There  are  no  contra-indi  cations  for 
its  use  save  possibly  gastric  sensitiveness. 

For  local  antisepsis,  boric  acid,  carbolic  acid,  biborate  of  soda,  creolin, 
and  mercury  bichlorid  are  the  most  reliable  remedies.     The  principal  ob- 


^  The  Garrod  Spa,  manufactured  by  the  Enno  Sander  Company,  is  one  of  the  best 
of  the  artificial  lithia-waters. 


DIET    IX    GEXITO-UEIXAKY    DISEASE.  3 

stacle  to  the  apiDlication  of  local  measures  is  the  extreme  sensitiveness  of  the 
vesical  neck  and  the  mechanic  disturbance  necessarily  attendant  npon  irri- 
gation, however  it  may  be  practiced. 

Another  important  consideration  in  reducing  acidity  of  urine  is  atten- 
tion to  diet.  It  is  probable  that  few  patients  can  subsist  on  a  non-nitrog- 
enous diet  for  any  length  of  time  without  causing  a  greater  or  less  degree 
of  alkalinity  of  urine.  The  value  of  a  vegetable  diet,  therefore,  is  self- 
evident. 

It  should  be  remembered,  however,  that  certain  vegetables  are  objec- 
tionable as  imparting  irritating  priiiciples  to  the  urine.  Thus,  rhubarb  and 
tomatoes  contain  oxalic  acid  and  are  especially  injurious  iii  inflammations 
of  the  urinary  tract.  Asparagus  is  also  open  to  impeachment.  Acid  fruits, 
also,  are  generally  to  be  interdicted. 

The  ideal  diet,  although  not  entirely  non-nitrogenous,  is  Ijread  and 
milk.  Milk  is  mildly  alkaline  in  reaction,  and  if  taken  in  large  quantities, 
providing  the  patient  abstains  from  meat,  produces  a  neutral  or  faintly- 
alkaline  urine.  It  also  dilutes  and  adds  to  the  watery  constituents  of  the 
urine.  The  best  practice  in  all  inflammatory  troubles  of  the  genito-urinary 
tract  is  to  confine  the  patient  to  a  diet  of  which  milk  is  the  basis.  The 
author  has  treated  experimentally  many  cases  of  acute  gonorrhea  by  an 
exclusive  diet  of  bread  and  milk  and  the  administration  of  the  acetate  of 
potassium.  With  no  other  remedies  than  these  the  inflammatory  symptoms 
have  promptly  subsided.  Such  a  j^lan  of  treatment  is  the  only  safe  one  in 
the  majority  of  eases  of  sharply-acute  urethritis  in  the  early  stages.  Anti- 
septics and  astringents,  with  or  without  balsams,  will  quite  likely  become 
necessary  in  a  certain  proportion  of  cases,  after  the  acute  symptoms  have 
begun  to  subside,  but,  as  a  rule,  it  is  not  Avise  to  adopt  treatment  that  is  in 
the  least  degree  stimulating  for  the  first  week  or  two  after  the  beginning  of 
urethritis.  It  is  probable  that  if  all  patients  with  acute  inflammation  of  the 
bladder  or  urethra  were  treated  with  a  bread-and-milk  diet,  conjoined  with 
rest  and  simple  diluent  remedies,  they  would  almost  invariably  do  well. 
The  frequency  of  complications  and  sequels  would  certainly  be  reduced 
to  a  minimurn  and  their  severity  greatly  diminished.  Chronic  cases  some- 
times recover  completely  after  suspension  of  all  astringent  and  balsamic 
preparations,  the  patient  subsisting  for  a  few  weeks  entirely  upon  bread 
and  milk. 

The  question  of  tobacco  and  stimulants  is  of  vital  importance  in  the 
general  management  of  genito-urinary  and  venereal  diseases.  In  a  large 
proportion  of  cases  the  patient's  remissness  in  this  respect  is  a  serious 
obstacle  to  successful  treatment.  Both  tobacco  and  liquor  tend  to  produce 
an  irritable  condition  of  the  nervous  system  as  well  as  irritation  of  the 
mucous  membranes.  Alcohol,  being  eliminated  largely  by  the  kidneys,  is 
especially  irritating  to  the  genito-urinary  tract.  It  also  has  an  especially 
exciting  effect  upon  the  sexual  organs. 


4  GEXITO-UEIXAEY    AXD    SEXUAL    HYGIEXE. 

AA'ith  reference  to  the  action  of  tobacco,  the  author  believes  that  it  has 
a  pronounced  deleterious  effect  upon  the  genito-urinary  tract.  Patients 
with  inflammatory  affections  of  the  urethra;,  prostate,  bladder,  and  kidneys 
certainly  do  better  when  they  abstain  from  tobacco.  In  syphilis,  as  will 
be  noted  later,  the  evil  effects  of  both  tobacco  and  alcohol  are  not  only 
familiar,  but  readily  explicable. 

Certain  varieties  of  alcoholic  beverages  are  particularly  open  to  im- 
peachment as  regards  their  deleterious  action  upon  the  genito-urinary  tract. 
Beer,  champagne,  and  such  wines  as  port  and  Burgundy  are  worse  in  this 
respect  than  a  pure  article  of  whisky  or  brandy,  although  the  latter  is  bad 
enough.  In  general,  it  may  be  said  that  abstinence  from  alcohol  and  to- 
bacco is  the  key-note  of  success  in  the  management  of  a  large  proportion 
of  cases  of  genito-urinary  disease.  Tea  and  coffee  are  usually  to  be  inter- 
dicted in  acute  affections  of  the  genito-urinary  tract. 

Another  vital  point  is  the  condition  of  the  skin  and  bowels.  If  these 
eliminative  areas  do  not  functionate  properly,  the  kidneys  must  necessarily 
be  called  upon  to  act  vicariously,  the  resultant  increase  in  urinary  solids 
making  the  urine  much  more  irritating.  A  primary  indication,  therefore, 
is  to  increase  the  secretion  of  the  skin,  thus  removing  a  certain  amount 
of  waste-material  that  would  otherwise  make  the  urine  extremely  acid. 
This  is  especially  necessary  with  patients  of  a  rheumatic  or  gouty  diathesis, 
who  usually  eat  and  drink  to  excess. 

The  skin  and  bowels  may  be  stimulated  by  very  simple  remedies.  The 
Turkish  bath  is  useful  in  increasing  sudoriparous  secretion  and  elimination, 
and,  in  lieu  of  it,  ordinary  hot  baths  are  quite  efficient,  while  such  simple 
laxatives  as  compound  licorice  powder  or  any  of  the  saline  laxative  mineral 
waters  are  usually  suflficient  to  keep  the  bowels  active. 

In  referring  to  the  value  of  hot  baths  in  the  special  class  of  morbid 
conditions  coming  within  the  province  of  this  Avork.  their  use  in  the 
venereal  diseases  is  worthy  of  special  consideration.  Frecjuent  general  hot 
baths  in  syphilis  are  an  essential  feature  of  its  rational  therapeutics.  Hot 
sitz-baths  are  of  great  value  in  chancroid,  bubo,  gonorrhea,  and  all  simple 
inflammatory  affections  of  the  genitals  and  their  environs. 

It  is  very  important  to  avoid  chilling  of  the  body,  particularly  the 
lower  limbs,  in  all  affections  of  the  genito-urinary  tract.  Exposure  is  often 
responsible  for  aggravation  of  inflammation  and  the  intercurrence  of  com- 
plications. An  equable  temperature  of  the  skin  is  a  sine  qua  non  in  the 
management  of  chronic  genito-urinary  affections  in  old  men  and  in  renal 
diseases  at  all  ages  and  in  both  sexes.  Chilling  of  the  general  surface  is 
always  dangerous  in  renal  disease.  Local  chilling — as  of  the  lumbar,  hypo- 
gastric, and  perineal  regions — is  especially  to  be  avoided. 

The  most  important  of  all  indications  in  the  treatment  of  inflamma- 
tory troubles  of  the  genito-urinary  organs  is  the  maintenance  of  perfect 
rest.    Indeed,  the  neutralization  of  urinarv  aciditv  is  reallv  one  element  in 


BEST   IN    GEXITO-rEIXAEY    DISEASE.  -J 

promoting  rest  of  the  inflamed  mucous  membrane,  Just  as  truly  as  avoidance 
of  dust  is  an  important  factor  in  resting  an  inflamed  eye.  With  the  majority 
of  persons  suffering  from  such  diseases,  rest,  in  the  strict  sense  of  the  term, 
is  a  difficult  thing  to  secure.  Patients  do  not,  or  will  not,  understand  its 
importance.  They  expect  to  be  cured  while  going  about  attending  to  busi- 
ness and  social  duties.  In  deference  to  professional  routine,  and  a  desire  to 
retain  the  patient,  the  surgeon  is  usually  compelled  to  treat  his  cases  as 
best  he  may  while  the  patient  is  on  his  feet  and  actively  exercising  when 
he  really  should  be  completely  at  rest,  even  to  the  extent  of  going  to  bed 
for  a  week  or  ten  days.  It  is,  of  course,  not  alwaj^s  absolutely  necessary  or 
practicable  for  him  to  lie  in  bed,  but  such  a  course  is  certainly  indicated  in 
the  majority  of  cases.  The  snrgeon  should  at  least  instruct  the  patient  to 
keep  as  quiet  as  possible  and,  so  far  as  he  can,  to  avoid  walking  and 
unnecessary  muscnlar  exercise  during  the  existence  of  acute  inflammation. 
Physical  rest  is  obviously  easier  to  secure  in  women  with  genito-urinary  and 
sexual  disorders  than  in  men. 

In  cases  of  inflammation  of  the  prostate  or  bladder  it  is  often  absolutely 
necessary  to  order  the  patient  to  bed  for  a  greater  or  less  length  of  time. 
The  author  has  seen  cases  of  bpth  acute  and  chronic  prostatitis  that  had 
been  treated  in  every  conceivable  Avay  without  benefit  completely  recover 
after  two  or  three  months  in  bed.  One  case  in  particular  was  that  of  a 
physician  sufl^ering  from  a  prostatitis  of  five  or  six  months'  standing.  He 
had  been  treated  by  nearly  all  known  methods  at  the  hands  of  a  number  of 
competent  physicians  without  apparent  benefit.  He  was  ordered  to  bed, 
with  instructions  to  keep  perfectly  quiet.  The  treatment  consisted  entirely 
of  alkaline  reiuedies  and  counter-irritation  of  the  perineum,  with  an  ex- 
clusive diet  of  bread  and  milk.  This  course  was  persisted  in  for  several 
months,  resulting  in  complete  recovery.  Confinement  to  bed  compels  com- 
plete rest — something  Avhich  it  is  not  practicable  to  accomplish  in  any  other 
way.  It  must  be  remembered  that  a  patient  can  hardly  move — he  certainly 
cannot  take  a  step — without  irritating  the  inflamed  prostate  and  bladder. 
The  prostate  in  cases  of  acute  inflammation  is  sometimes  the  size  of  a  small 
orange;  under  such  circumstances  the  slightest  motion  of  the  thighs  will 
cause  mechanically  more  or  less  pain  and  irritation.  Then,  too,  the  erect 
posture  tends  to  cause  congestion  and  irritation  of  tbe  inflamed  organ,  with 
resultant  enhancement  of  inflaiumation. 

The  necessity  of  physical  rest  is  not  all  that  must  be  impressed  upon 
the  patient's  mind;  an  attempt  should  be  made  to  secure  sexual  rest  as  well. 
This  is,  of  necessity,  diflficult  of  accomplishment.  A  patient  with  a  broken 
leg  is  compelled  to  take  rest, — indeed,  he  cannot  move  without  being  pun- 
ished for  his  indiscretion, — the  injured  limb  being  securely  bound  in  splints, 
rendering  movement  of  the  affected  part  well-nigh  impossible.  A  patient 
sufl^ering  from  pneumonia  has  his  chest  incased  in  hot  poultices  or  the 
ice-pack,  insuring  rest  for  the  inflamed  lung.     Even  in  genito-urinary  dis- 


6  GEXITO-URIXAEY    AXD    SEXUAL    HYGIEXE. 

eases  physical  rest  is  comparatively  easy  to  secure;  the  patient  may  often 
be  kept  in  Ijed  so  long  as  the  physician  deems  necessary.  Unfortunately, 
hoAvever,  it  is  not  so  easy  to  keep  the  patient's  thoughts  diverted  from  his 
sexual  organs,  which,  unlike  a  fractured  leg  or  inflamed  lung,  may  he  irri- 
tated hy  psychic  stimuli.  Many  morbid  conditions  of  the  sexual  apparatus 
are  due  to  reflex  sexual  irritation  through  psychic  impressions.  Very  often 
the  patient  reads  a  great  deal  of  literature  of  a  more  or  less  erotic  nature,  or 
allows  his  mind  to  dwell  upon  sexual  affairs:  and  as  a  consequence  the 
sexual  organs  are  never  at  rest.  It  is  probable,  moreover,  that  every  conti- 
nent man  suffers  more  or  less  from  sexual  starvation. 

The  male  sex  is  not  alone  in  respect  to  sexual  craving;  women  some- 
times suffer  from  the  same  difficulty.  Quite  recently  a  young  woman  con- 
sulted the  author  for  this  trouble.  She  stated  that  she  was  annoyed  con- 
tinually by  sexual  excitement.  She  was  undoubtedly  virtuous,  intelligent, 
well  educated  and  refined,  and  suspicious  of  the  existence  of  some  obscure 
uterine  trouble  that  might  account  for  her  ailment.  She  was  averse  to 
examination,  but  Avas  probably  suff'ering  from  some  inflammatory  affection 
of  the  uterus  or  ovaries,  causiu'ii'  reflex  excitement:  i.e.,  sexual  hyperesthesia. 
She  stated  that  she  was  greatly  annoyed  by  peculiar,  quivering  sensations 
about  the  uterus  attended  In*  emissions  of  fluid  of  some  kind  occurring 
daily.  As  is  well  known,  women  do  not  have  true  emission  during  inter- 
course, the  seeming  emission  feeing  an  excessive  secretion  of  the  mucus  that 
normally  lubricates  the  genital  tract.  This  mucus  constituted  the  so-called 
"emissions"  in  this  instance.  Such  cases  demonstrate  that  sexual  starvation 
is  met  with  in  both  sexes,  though  Avomen  are  not  so  likely  as  men  to  under- 
stand the  situation.  A  great  many  females  thus  affected  realize  that  they 
are  ailing,  but,  being  essentially  jnire-minded.  do  not  ascribe  their  troubles 
to  the  real  source — sexual  starvation.  Hysteria,  melancholia,  hypochondria, 
and  other  nervous  conditions  in  women  may  result  reflexly  from  irritation 
of  the  sexual  apparatus.  Irritation  of  the  uterus  and  ovaries  may  be  due 
to  that  instinctive  jiliysiologic  craving  with  which  every  normal  womafi, 
however  pure,  is  endowed. 

The  use  of  the  term  '"sexual  starvation"  may  be  criticised  adversely:  so 
it  might  be  well  to  call  attention  to  the  fact  that  sexual  affinity  itself  has 
been  asserted  by  biologists  to  be  a  refinement  of  hunger,  which  is  the  real 
foundation  of  sexual  desire. 

Hysteria,  melancholia,  and  hyjiochondria  in  the  male  are  more  often 
met  with  as  a  consequence  of  irritation  of  the  sexual  organs,  and  especially 
the  prostate,  than  is  generally  recognized.  Ungratified  sexual  desire  is  quite 
often  responsible  for  such  nervous  affections  in  men. 

The  necessity  for  a  proper  performance  of  the  sexual  function  may  not 
be  recognized  l)y  the  individual  most  concerned,  yet  it  exists  in  every  adult 
human  being  who  is  nnrnially  constituted.  Xo  man  or  woman  at  adult 
age  is  in  perfect  physiologic  condition  until  the  sexual  function  is  naturally 


EEGULATIOX    OF    THE    SEXUAL    FU^X'TIOX.  7 

and  regularly  iDerformed.  It  is  not  merely  the  sexual  act,  the  orgasm  and 
discharge  of  semen  in  the  male,  or  the  orgasm  and  reception  of  semen  in 
the  female,  that  is  essential  to  the  relief  of  sexual  starvation,  but  there  should 
rightfully  be  a  physiologic  purpose  in  the  performance  of  the  procreative 
function.  This  is  not  usually  accomplished  save  in  the  matrimonial  state. 
The  sexual  appetite  of  the  average  man  diminishes  after  a  variable  period 
of  normal,  regular  gratification,  and  lie  no  longer  gives  himself  special  con- 
cern regarding  his  sexual  function;  in  fact,  he  concerns  himself  no  more 
than  he  does  about  the  function  of  his  bowels  or  bladder.  He  lives  con- 
tentedh',  as  regards  his  sexual  organs,  and  fulfills  his  matrimonial  obliga- 
tions in  a  quite  perfunctory  fashion.   . 

Modern  society,  unfortunately,  imposes  conditions  that  make  sexual 
excitement  without  gratification  very  common.  The  methods  of  dancing 
at  present  in  vogue  are  responsible  for  this  to  a  certain  degree.  The  inti- 
mate contact  of  the  sexes  that  dancing  permits,  associated  with  the  emo- 
tional effect  of  music,  cannot  fail  to  produce  more  or  less  erotism  in  certain 
susceptible  individuals.  Pure-mindedness  is  not  always  a  safe-guard,  for 
physiologic  law  is  likely  to  be  more  potent  than  psychic  purity.  Sexual 
stimulation  and  erotic  excitement  by  no  means  necessarily  require  sexual 
thought  as  their  basis. 

The  most  unfortunate  feature  of  it  all  is  that  society  offers  less  induce- 
ment to  matrimony  than  formerly.  The  average  young  man  of  to-day 
Justly  considers  matrimony  a  too  expensive  luxury.  In  the  case  of  women 
the  matrimonial  problem  is  still  more  difficult.  They  are  debarred  by  social 
custom  from  taking  the  initiative.  Taken  all  in  all.  intelligent  physicians 
and  sociologists  alike  are  united  in  the  belief  that  the  existing  conventional 
extramatrimonial  relations  of  the  sexes  are  not  physiologic,  however  moral 
they  may  be. 

Literature  of  a  romantic  and  erotic  character  is  often  even  Avorse  than 
dancing  sometimes  is  in  its  pernicious  effects  upon  the  sexual  system. 
Especially  is  this  true  of  individuals  at  about  the  age  of  puberty. 

There  are  ways  and  means  to  prevent,  or  at  least  limit,  the  injurious 
effects  caused  by  sexual  stimulation  without  gratification;  fornication,  how- 
ever, is  not  one  of  them.  The  fear  of  evil  consequences  alone  makes  such 
a  course  decidedly  unphysiologic.  Masturbation  only  serves  to  make  matters 
physically  worse,  irrespective  of  its  demoralizing  effects. 

The  best  moral  educator  for  young  men  is,  in  the  author's  opinion,  the 
gymnasium.  The  resultant  physical  improvement  might  seem  likely  to  in- 
crease sexual  activity.  Such  is  not  the  case,  however.  The  most  vigorous 
individual  is  not  always  the  most  amorous.  The  man  who  studies  very  hard, 
or  is  engaged  in  an  intellectual  occupation  that  fosters  an  excitable  state  of 
the  nervous  system  and  exaggerates  nervous  sensibility  and  emotionalism, 
is  likely  to  be  more  intemperate  in  his  sexual  relations  than  the  hard-work- 
ing laborer.    It  will  be  noticed,  however,  that  the  laboring  man  is  generally 


8  GENITO-UEIXARY    AND    SEXUAL    HYGIEXE. 

the  one  who  has  the  most  children.  The  individual  who  most  frequently 
seeks  sexual  gratification  is  not  usually  distinguished  by  either  the  number 
or  good  health  of  his  progeny.  He  who  is  most  temperate  sexually  is  usually 
best  fitted  for  procreation,  because,  from  a  sexual  point  of  view,  most  ener- 
getic. Frequent  intercourse  causes  decided  deterioration  in  the  quantity 
and  fructifying  quality  of  the  semen.    This  is  well  known  to  stock-breeders. 

It  is  a  cardinal  rule  that  overexcitement  of  any  function  will  cause 
loss  of  power.  It  is  quite  generally  known  that  the  males  of  the  Orient 
become  impotent  earlier  than  other  men  because  of  excessive  indulgence  of 
their  sensual  appetites,  conjoined  with  a  life  of  indolence  and  ease.  The 
youth  who  indulges  in  sexual  intercourse  most  frequently  is  the  one  who 
will  be  most  likely  to  become  impotent  or  sterile  at  middle  age.  This  holds 
true  with  all  peoples  the  world  over.  The  surgeon  is  very  often  consulted 
by  men  approaching  middle  age  who  complain  that  they  cannot  indulge 
their  sexual  appetite  as  frequently  as  formerly,  and  ask  for  remedies  where- 
with to  whip  up  the  jaded  function.  To  such  patients  he  should  say: 
"You  are  paying  for  your  early  excesses,  and  cannot  expect  to  perform 
the  sexual  act  so  often  as  you  did  when  but  eighteen  or  twenty  3^ears  old. 
The  magazine  is  almost  exhausted."  This  answer  may  not  satisfy  the  pa- 
tient, perhajDS,  but  it  is  certainly  conscientious.  A  great  many  patients 
complain  of  real  or  imaginary  sexual  exhaustion,  spermatorrhea,  or  prema- 
ture old  age,  and  if  the  surgeon  does  not  understand  the  physiologic  con- 
ditions involved,  he  certainly  cannot  manage  such  cases  satisfactorily. 

As  already  stated,  we  may  alleviate  sexual  irritability  and  excessive 
desire  through  the  physical  system,  by  giving  the  patient  some  occupation 
that  will  necessitate  muscular  exercise,  diverting  his  superfluous  nervous 
energy  in  the  direction  of  his  muscles.  He  may  also  be  benefited  through 
the  medium  of  the  mind.  He  should  be  kept  occupied  with  something  that 
will  serve  to  divert  his  thoughts  from  the  sexual  organs.  Literature  of  an 
erotic  or  prurient  nature  and  female  society  of  a  doubtful  character  should 
be  forbidden.  Good  literature  and  the  society  of  refined  women  are,  how- 
ever, a  sine  qua  non.  In  many  instances  sedative  and  anaphrodisiac  remedies 
are  of  great  service. 

If  marriage  be  practicable  and  the  patient  has  no  organic  disease,  it 
is  well  to  advise  it,  irrespective  of  the  patient's  confidence  in  his  ability  to 
perform  the  matrimonial  act.  Impotency  in  the  average  young  man  is  a 
myth.  He  is  generally  capable  of  exhibiting  as  much  sexual  prowess  as  will 
ever  be  required  of  him  legitimately. 

As  a  rule,  to  which  there  are  few  exceptions,  marriage  is  permissible 
providing  the  sexual  organs  are  normally  developed  and  objectively  sound 
and  the  patient  is  otherwise  healthy.  Caution  should  be  exercised  in 
advising  matrimony,  however.  It  is  quite  the  fashion  for  physicians  to 
prescribe  matrimony  for  the  cure  of  pathologic  conditions  in  the  male, 
with  a  total  disregard  for  the  interests  of  the  female  party  to  the  prescrip- 


MAKKIAGE   AS    A    EEMEDY.  \) 

tion.  The  custom  of  prescribing  virgins  for  Avorn-out  roues  and  men  suifer- 
ing  from  physical  ills,  infectious  or  otherwise — conditions  for  which  the 
patient  is  himself  alone  responsible — is  more  popular  than  it  should  be. 
Pure  women  should  not  be  considered  as  remedial  agents  to  be  prescribed 
solely  with  regard  to  the  interests  of  the  consumer — of  which  more  anon. 

With  reference  to  the  results  of  matrimony  under  proper  conditions, 
it  is  safe  to  say  that  the  average  sufferer  from  more  or  less  imaginary  sexual 
woes  is  not  likely  to  have  any  cause  for  complaint  after  marriage,  so  far 
as  his  sexual  function  is  concerned. 


CHAPTER  II. 

UrIXALYSIS    IX    ITS    SUEGICAL    PiELATIOXS. 

The  various  standard  treatises  upon  genito-urinarv  diseases  devote  but 
little  attention  to  the  special  characters  of  the  urine  in  the  various  dis- 
eases coming  under  the  observation  of  the  surgeon.  Such  attention  as  is 
given  to  urinalysis  from  a  surgical  stand-point  is  merely  incidental  to  the 
description  of  the  diseases  of  the  genito-urinary  tract,  and  is  very  meagre. 
This  seems  somewhat  strange,  too,  in  view  of  the  important  information 
that  may  often  be  obtained  from  a  careful  study  of  the  urine  in  different 
surgical  diseases,  parti ctdarly  those  involving  the  genito-urinary  organs. 
It  seems  fitting,  therefore,  in  a  work  of  this  kind,  that  a  chapter  should  be 
devoted  to  the  special  consideration  of  urinalysis  in  its  surgical  relations. 
The  technic  of  urinary  chemistry  and  microscopy  is,  of  course,  beyond  the 
province  of  this  work. 

Maceoscopic  Study  of  the  Ueixe. — It  is  desirable  for  the  surgeon 
to  so  familiarize  himself  with  the  gross  physical  characters  of  the  urine 
voided  in  different  diseases  that  he  can  form  a  fairly  accurate  estimate  of 
the  condition  of  the  genito-urinary  organs  without  an  exhaustive  chemic 
and  microscopic  examination.  To  pursue  accurate  investigations  in  the 
minidice  of  urinah'sis,  considerable  technic  knowledge  of  analytic  chemistry 
and  of  the  science  of  microscopy  is  necessary;  but,  for  the  application  of 
pathologico-chemic  facts  and  the  main  features  of  urinary  microscopy  to 
the  diagnosis  of  genito-urinary  diseases,  a  moderate  degree  of  familiarity 
with  microscopic  and  chemic  technic  is  amply  sufficient. 

Todd  has  wisely  said  that,  '•'Although  it  is  clearly  a  duty  not  to  neglect 
any  means  of  observation  and  investigation,  it  is  desirable  that  we  should 
be  as  little  as  possible  dependent  upon  means  that  are  not  always  at  hand, 
and  which  it  does  not  fall  to  the  lot  of  every  eye  and  hand  to  use  with 
equal  readiness  and  skill."  The  greatest  of  modern  pathologists.  Professor 
Yirchow,  has  expressed  himself  in  a  somewhat  similar  manner  as  regards 
what  he  has  aptly  termed  "naked-eye  pathology."  The  experience  of 
most  practical  pathologists  is  corroborative  of  the  assertion  of  this  eminent 
authority  that  microscopic  characters  may  often  be  anticipated  by  a  con- 
scientious and  expert  macroscopic  examination. 

It  is  not  the  author's  intention  to  take  up  the  subject  of  urinalysis  in 
detail,  nor,  indeed,  in  general,  excepting  in  so  far  as  it  applies  more  or 
less  directly  to  surgical  diseases. 

Quantity  of  Urine.- — The  quantity  of  urine  varies  greatly  even  in  health, 
the  amount  excreted  being  dependent  upon  a  number  of  circumstances.  The 
urine  varies  considerablv  in  amount  with  the  season  of  the  vear,  being 

(10) 


PEOPORTIOX    OF    UEIXAEY    SOLIDS.  11 

most  abimdant  during  the  winter  months.  This  variation  is  due  to  the 
decreased  activity  of  the  skin  in  cold  weather.  The  weather  also  modifies 
the  chemic  properties  of  the  urine;  thus,  in  summer  the  raprd  and  profuse 
excretion  of  fluid  by  the  skin  not  only  diminishes  the  amount  excreted  by 
the  kidneys,  but,  2^<^^"''  passu  with  this  diminution  in  quantity,  we  note, 
under  normal  circumstances,  an  increase  in  the  proportionate  amount  of 
excreted  solids. 

The  cj[uantity  of  urine  is  obviously  modified  by  the  character  of  the 
food  and  drink.  A^egetable  diet,  which  contains  a  large  proportion  of  fluid 
in  its  composition,  produces  a  larger  excretion  of  urine  than  does  purely 
animal  food.  The  amount  of  fluid  ingested  necessarily  modifies  the  quantity 
of  urine  more  than  any  other  circumstance.  Tlie  condition  of  the  bowels 
is  also  of  great  imjjortance.  A  patient  with  diarrhea  is  likely  to  excrete 
urine  in  scanty  amount.  This  is  well  illustrated  in  Asiatic  cholera,  in  which 
complete  suppression  of  urine  eventually  occurs,  being  explicable,  at  least 
in  part,  by  the  rapid  removal  of  fluid  from  the  blood  by  the  bowel-evacua- 
tions. 

The  condition  of  the  kidneys  modifies  the  quantity  of  urine  as  well  as 
its  proportion  of  solids.  Much  depends  upon  the  condition  of  the  nervous 
system,  vasomotor  disturbances  being  productive  of  an  increase  or  decrease, 
as  the  case  may  be,  in  the  amount  of  excreted  urine.  Thus,  we  have  a  con- 
dition of  hydruria,  or  excessive  amount  of  watery  secretion  from  the  kidneys, 
in  cases  of  diabetes  insipidus,  in  which  the  daily  urinary  flow  may  amount 
to  from  7000  to  10.000  cubic  centimeters,  the  specific  gravity  being  very 
often  as  low  as  1002.  Persons  of  highly  nervous  or  hysteric  temperament 
are  not  infrequently  affected  by  this  condition.  It  is  a  not  uncommon 
experience  for  those  who  are  subjected  to  mental  strain  or  anxiety,  or  to 
the  emotions  of  anger  or  fright,  to  have  an  enormous  increase  in  the  quantity 
of  urine.  Students  undergoing  the  ordeal  of  examination  are  quite  apt 
to  be  affected  by  hydruria.  The  term  hydruria  is  properly  applied  only  to 
that  form  of  excessive  urinary  secretion  in  which  there  is  a  marked  increase 
of  fluid  with  a  co-existent  diminution  of  solids.  When  the  increase  of  water 
is  attended  with  an  increase  in  the  amount  of  urinary  solids  from  exagger- 
ated tissue-metabolism,  the  condition  is  properly  termed  polyuria. 

Proportion  of  Urinary  Solids. — The  proportion  of  solids  contained  in 
the  urinary  fluid  is  modified  by  the  same  influences  as  those  affecting  the 
quantity  of  the  excreted  fluid,  and  is  a  vital  point  in  the  study  of  genito- 
urinary diseases. 

A  very  simple  method  of  determining  approximately  the  amount  of 
solids  in  the  urine  is  given  by  Flint.  The  specific  gravity  of  the  urine  is 
to  be  taken,  and  between  1010  and  1030  it  will  be  found  that  the  last  two 
figures  of  the  specific  gravity  represent  tolerably  accurately  the  number  of 
grains  of  solids  excreted  in  each  ounce  of  the  fiuid.  By  ascertaining  the 
total  number  of  ounces  excreted  in  the  twenty-four  hours  we  can  readily 


12  TKIXALYSIS    IN    ITS    SURGICAL    EELATIOXS. 

determine;,  with  sufficient  accuracy  for  most  practical  purposes,  the  total 
amount  of  solids  excreted.  This  is  important  as  showing  whether  the  kid- 
neys are  performing  their  functions  sufficiently  well  to  obviate  the  danger 
of  uremia  in  certain  diseases/  In  making  this  estimate  of  the  quantity  of 
solids  excreted  it  is  necessary  to  take  into  consideration  the  quantity  and 
quality  of  the  food  and  drink.  The  determination  of  the  amount  of  solids 
excreted  during  the  twenty-four  hours  may  be  a  ver}^  important  considera- 
tion in  connection  with  operations  upon  the  genito-urinary  organs.  Indeed, 
it  may  influence  us  either  to  avoid  or  ^Derform  an  o^Deration  in  cases  in  which 
the  amount  of  albumin  is  of  negative  importance. 

Diet  and  exercise  modify  the  amount  of  solids  very  markedly.  Thus, 
a  diet  of  highl3'-nitrogenized  food  increases  the  amount  of  solids,  and  par- 
ticularly urea,  to  a  marked  degree,  causing  a  condition  described  by  Fuller 
as  haruria,  with  a  large  increase  in  the  total  amount  of  urinary  solids.  Urine 
of  this  character  is  very  concentrated,  and  urates  are  usually  deposited. 

This  condition  of  the  urine  characterizes  the  systemic  condition  termed 
by  Murchison  Utliemia.  This  state  of  the  blood  bears  an  intimate  relation 
to  urinar}^  calculus,  and  various  irritative  and  inflammatory  affections  of 
the  genito-urinary  tract.  The  late  Andrew  Clark  described  a  condition 
known  as  renal  inadequacy,  in  which  there  is  a  notable  deficiency  in  the 
amount  of  urea  excreted,  without  marked  or  constant  change  in  the  amount 
of  fluid  passed.  He  failed  to  show,  however,  whether  this  condition  depends 
upon  insufficient  renal  action  or  upon  deficient  tissue-metabolism.  Either 
condition  may  be  effective  in  its  causation,  and  it  is  safe  to  assume  the  possi- 
bility of  a  combination  of  both.  The  quantity  of  urine  and  the  proportion 
of  fluid  and  solid  ingredients  are  two  of  the  most  important  points  to  be 
considered  in  connection  with  the  various  surgical  affections  of  the  genito- 
urinary tract.  If  perfectl}'  familiar  with  the  conditions  that  modify  the 
composition  and  amomit  of  the  urine,  the  surgeon  will  have  a  distinct 
advantage  in  the  management  of  these  diseases.  Thus,  in  diseases  of  a  cal- 
culous or  inflammatory  character  it  is  obviously  desirable  to  increase  so  far 
as  possible  the  proportion  of  urinary  fluid,  and  decrease  the  amount  of  solids, 
without  interfering  with  the  elimination  by  the  system  of  those  substances 
usually  taken  care  of  by  the  kidneys.  This  may  be  accomplished  by  diet, 
rest  or  modification  of  exercise,  hot  baths,  the  administration  of  large  quan- 
tities of  fluid,  and  various  diuretic  remedies. 

Another  important  consideration  is  the  condition  of  the  digestive  ap- 
paratus, for  if  the  functions  of  the  stomach  and  liver  be  impaired  there  will 
be  present  in  the  urine  more  or  less  crude  products  of  tissue-metabolism. 
Thus,  instead  of  a  comjDlete  metamorphosis  of  proteids  the  termination  of 
which  should  be  the  production  of  urea,  there  is  likely  to  occur,  as  a  result 


^  The  term  "uremia"'  is  used  conventionally.     It  is  beginning  to  be  known  that 
urea  is  a  trivial  factor  in  urinary  toxemia.     It  is  something  of  a  '"bugaboo." 


SPECIFIC    GKAVITY,    COLOK,    AND    ODOE    OF    THE    URIXE.  13 

of  imperfect  preparation  of  the  food  by  the  digestive  apparatus,  a  cessation 
of  the  process  midway,  with  resulting  formation  of  uric  or  lithic  acid.  This 
is  one  of  the  establislied  causes  of  lithemia.  The  degree  to  which  imperfect 
oxidation  may  contribute  to  this  state  of  affairs  is  a  matter  of  controversy. 
It  is  to  be  remembered  in  this  connection,  however, — and  seemingly  many 
writers  upon  the  subject  fail  to  appreciate  this  fact, — that  excessive  quan- 
tity and  imperfect  preparation  for  assimilation  of  certain  food-elements 
are  not  the  only  circumstances  upon  which  lithemia  depends,  for  there  may 
be  a  normal  proportion  and  perfect  preparation  of  proteids  by  the  digestive 
apparatus  which  fails  of  its  object  because  of  defective  tissue-metabolism. 
Behind  this  defective  chemism  lie  nervous  perturbations  as  yet  undefined, 
modifying  the  nervous  influences  that  preside  over  tissue-nutrition  and  the 
various  glandular  functions. 

It  is  necessary,  therefore,  in  considering  the  ways  and  means  of  lessen- 
ing the  irritating  properties  of  the  urine,  to  take  into  consideration  the 
amount  and  quality  of  the  food,  the  activity  of  those  physiochemic  changes 
the  function  of  which  is  the  final  disposition  of  the  nutrient  pabulum,  and 
the  condition  of  the  nervous  system.  This  question  is  of  more  importance 
to  the  surgeon  than  is  evident  upon  superficial  observation,  as  will  be  seen 
in  connection  with  the  subject  of  urinary  calculi. 

Specific  Gravity,  Color,  and  Odor  of  the  Urine. — These  qualities  are  in- 
terdependent and  vary  considerably,  being  dependent  upon  the  same  cir- 
cumstances as  those  affecting  the  quantity  of  the  fluid  and  its  proportion  of 
solids.  Urine  containing  a  large  proportion  of  solids  has  a  high  color,  as 
a  rule,  with  high  specific  gravity.  The  urine  of  hydruria  is  pale  and  limpid, 
and  of  low  specific  gravity.  This  is  seen  in  some  cases  of  surgical  and  granu- 
lar kidney.  The  urine  of  lithemic  or  gouty  subjects  is  of  high  color  and  high 
specific  gravity.  Urine  of  low  specific  gravity  has  comparatively  little  odor. 
Xormal  urine  has  a  peculiar  aromatic  smell  that  grows  strong  and  pungent 
pari  passu  with  an  increase  in  its  proportion  of  solids.  Various  diseases  and 
the  ingestion  of  certain  drugs  modify  the  properties  of  the  urine  just  de- 
scribed. Blood  and  pus  modify  the  odor  to  a  certain  extent,  and  necessarily 
modify  the  color  in  proportion  to  the  amount  of  these  substances  present. 
Carbolic  acid,  the  preparations  of  iodin,  santonin,  and  methyl-blue,  taken 
internally,  modify  the  color  of  the  urine.  Certain  articles  of  diet  also 
modify  it.  Asparagus  gives  a  peculiarly-offensive  odor  and  dark  color  to 
the  urine.  Diuretics  of  various  kinds  increase  the  proportion  of  water  and 
consequently  lessen  the  pungency  of  the  urine  and  cause  it  to  become  paler. 
In  a  general  way,  the  urine  may  be  said  to  be  irritating  in  proportion  to 
its  height  of  color  and  degree  of  pungency. 

In  a  large  number  of  observations  upon  subjects  for  life-insurance 
examinations  the  author  has  noted  that  the  recent  ingestion  of  malt  liquor 
causes  a  marked  diminution  in  the  specific  gravity  and  an  increase  in  quan- 
tity of  the  urine  greater  than  could  possibly  result  from  the  mere  addition 


14  UEIXALYSIS    IX    ITS    SURGICAL    RELATIONS. 

of  an  extra  amount  of  fluid.  So  closely  associated  are  the  recent  ingestion 
of  malt  liquor  and  an  abnormally  low  specific  gravity  of  the  urine  that, 
when  the  fluid  has  a  specific  gravity  of  less  than  1015  (and  1010  is  fre- 
quent), the  author  immediately  suspects  that  the  applicant  has  recently 
been  drinking  beer.  In  the  majority  of  instances  this  suspicion  is  verified 
upon  inquiry.  There  is  an  apparent  inconsistency  in  this  observation. 
Malt  liquor  is  especially  irritating  to  the  genito-urinary  tract.  The  rapid 
passage  of  the  fluid  elements  of  the  beer  through  the  blood  and  kidneys  is 
associated  with  an  injurious  stimulation  incidental  to  the  alcohol  it  con- 
tains. Later  on,  the  excessive  nutriment  contained  in  the  beer,  especially 
the  proteids,  interferes  Avith  tissue-metabolism  and  makes  the  urine  heavy. 
Beer  also  deranges  the  function  of  the  liver,  which  adds  to  the  sum-total 
of  urinary  perturbation  by  disturbing  assimilation.  Copaiba,  cubebs,  sandal- 
wood, and  turpentine — drugs  that  bear  an  important  relation  to  genito- 
urinary surgery — markedly  modify  the  odor  of  the  urine.  Xormal  urine 
has  an  odor,  sui  generis,  that  has  been  described  as  aromatic.  L'rine  con- 
taining a  volatile  alkali  from  decomposition  emits  a  strong  ammoniacal 
odor.  AVhen  it  contains  a  fixed  alkali,  however,  the  odor  is  faint  and  dis- 
agreeable, something  like  the  urine  of  the  herbivora.  Urine  containing 
phosphates,  especially  of  lime,  speedily  decomposes  and  has  a  very  offen- 
sive odor. 

Eeadion  of  the  Urine. — The  reaction  of  normal  urine  varies  consider- 
ably at  dilferent  periods  of  the  day.  Tlie  urine  of  fasting  is  generally  quite 
acid,  becoming  neutral  or  perhaps  faintly  alkaline  a  short  time  after  the 
ingestion  of  food.  Bence  Jones  explains  this  diminution  in  the  acidity  of 
the  urine  by  the  abstraction  of  acid  from  the  circulation  for  the  supply  of 
the  gastric  juice.  Eoberts,  however,  is  inclined  to  regard  the  cbange  from 
acid  to  alkaline  as  due  to  the  introduction  of  alkaline  bases  from  the  freshly- 
digested  food  into  the  blood.  The  reaction  of  the  urine  is  markedly  modi- 
fied by  the  quality  and  quantity  of  the  food,  by  exercise,  and  by  various 
diseases  of  the  genito-urinary  tract.  Excessive  ingestion  of  proteids  greatly 
increases  its  acidity;  a  vegetable  diet  makes  it  alkaline.  Chronic  inflam- 
matory diseases  of  the  urinary  organs  usually  produce  alkalinity  of  the 
urine.  Thus,  in  chronic  prostatic  and  vesical  disease  the  reaction  may  be 
strongly  alkaline,  with  a  decided  odor  of  ammonia.  Strongly-acid  urine 
deposits  urates  upon  cooling,  while  alkaline  urine  deposits  phosphates.  It 
is  sometimes  desirable  to  differentiate  the  alkalinity  due  to  volatile  alkali 
dependent  on  ammoniacal  decomposition  from  that  due  to  a  fixed  alkali 
(potassium  or  sodium).  This  is  readily  done  by  observing  the  behavior  of 
red  litmus-paper  that  has  been  dipped  in  the  urine  and  allowed  to  dry. 
The  blue  color  produced  by  ammoniacal  urine  disappears  as  the  paper 
dries,  while  in  the  case  of  the  fixed  alkali  it  persists. 

Transparency  of  the  Urine. — The  clearness  of  the  urine  is  an  important 
consideration.     Urine,  though  dark,  may  be  perfectly  clear,  while  light 


TEANSPAKENCY    OF    THE    L'EI^'E.  15 

urine,  on  the  other  hand,  may  be  perfectly  opaque,  according  to  the  amount 
of  extraneous  matter  or  urinary  deposits  present.  Opaque  urine  may  be 
very  light  or  very  dark.  When  of  a  light  color  it  contains  either  earthy 
phosphates,  mucus,  or  pus,  singly  or  combined.  Mucus  is  more  apt  to 
form  a  distinct  cloud  in  the  urine  than  pus,  which,  from  its  higher  specific 
gravity,  sinks  to  the  bottom  of  the  vessel.  This,  however,  depends  some- 
what upon  the  character  and  origin  of  the  pus.  For  example:  in  pyelitis 
the  pus  is  powdery  and  easily  diffused  throughout  the  fluid,  while  in  cystitis 
or  abscess  emptying  into  the  bladder  it  forms  a  more  distinct  layer.  Puru- 
lent urine  may,  however,  be  completely  opaque,  with  a  distinct,  thick,  yel- 
lowish layer  of  corpuscles  at  the  bottom.  When  urine  is  turbid  from  either 
mucus,  pus,  or  salts,  it  should  be  filtered  before  a  critical  examination  is 
made.  When  the  urine  is  dark  and  opaque  it  may  contain  blood  or  bile. 
Carbolic-acid,  chlorate-of-potassium,  or  creasote  poisoning  makes  the  urine 
very  dark  and  o|)aque.  Chlorate  of  potassium  in  poisonous  doses  imparts 
in  some  instances  an  almost  black  color  to  the  urine,  due  to  hemoglobinuria. 
Any  drug  that  is  capable  of  producing  renal  irritation  and  inflammation 
may  produce  hemoglobinuria  or  hematuria.  Certain  diathetic  states,  such 
as  scurvy,  have  a  similar  effect.  Santonin  has  a  most  peculiar  effect  on 
the  urine.  A  single  dose  usually  imparts  a  bright-yellow  color,  lasting 
several  days.  If  the  urine  is  alkaline,  the  color  is  blood-red.  The  addition 
of  ammonia  also  turns  the  urine  red,  where  santonin  has  been  taken.  x\sso- 
ciated  with  the  peculiar  coloration  of  the  urine,  santonin  also  causes  marked 
vesical  irritation.  Santonin  in  its  passage  through  the  circulation  is  eon- 
verted  into  xanthopsin — this  produces  the  change  in  the  color  of  the  urine. 
Turbidity  of  the  urine  often  indicates  disease  of  the  genito-urinary  tract 
where  no  subjective  symptoms  of  disease  exist. 

Attention  has  been  called  to  the  relation  of  bacteria  of  various  forms 
to  more  or  less  marked  turbidity  of  the  urine.  Bacteria  of  various  forms 
may  be  found  in  the  urine  in  cases  in  which  there  are  no  definite  symp- 
toms of  organic  disease.  The  micrococcus  ureae,  vibrios,  rod-like  bacteria, 
and  spirilla  are  apt  to  be  met  with.^  As  many  as  six  different  varieties  of 
bacteria  have  been  found  in  a  single  specimen  within  three  hours  after 
micturition.  Urine  that  is  turbid  when  voided,  and  is  not  cleared  on  fil- 
tration, generally  contains  bacteria. 

Independently  of  bacteria,  turbidity  of  the  urine  is  apt  to  indicate  an 
unhealthy  state  of  the  mucous  membrane,  that  may  be  the  result  of  old 
organic  disease  or  of  present  slight  disturbance  which  may  later  on  become 
sufficiently  marked  to  attract  attention  and  require  treatment.  Bacteria 
may  be  implanted  upon  the  vesical  mucosa  by  septic  catheterization,  pro- 
ducing a  mild  degree   of  irritation   with  resultant   formation   of  mucus, 


^  Very  active  motile  bacteria  may  be  present  in  the  urine,  which,  clinically  at 
least,  have  no  especial  pathologic  significance. 


16  UKIK'ALYSIS    I^^    ITS    SUEGICAL    EELATIOXS. 

which  condition  is  capable,  under  favorable  circumstances,  of  progressing 
to  true  chronic  inflammation. 

In  making  observations  upon  the  lines  above  indicated,  great  care  is 
necessary  to  maintain  perfect  cleanliness  in  our  manipulations  of  the  urine. 

When  the  subject  of  bacteriuria  was  in  its  infancy,  the  author  had  an 
experience  bearing  upon  this  point  that  was  very  instructive  as  showing 
how  rapidly  the  urine  could  become  turbid  after  evacuation.  In  making 
life-insurance  examinations  the  applicant  was  requested  to  void  urine  into 
a  large-mouthed  bottle,  from  which  a  sample  was  taken  for  examination. 
This  bottle  was  thoroughly  rinsed  with  cold  water — which  under  the  cir- 
cumstances was  considered  sufficient  for  cleansing — before  and  after  use 
on  each  occasion.  It  had  been  observed  for  some  time  that  in  quite  a  pro- 
portion of  instances  the  urine  was  not  perfectly  clear  when  inspected  shortly 
after  it  was  voided,  and  upon  microscopic  examination  of  a  few  of  the 
specimens  they  were  found  to  be  swarming  with  bacteria.  It  was  noticed 
that  when  the  urine  was  examined  immediately  after  its  discharge  it  was 
clear  and  did  not  contain  bacteria.  The  explanation  was  finally  found  to 
be  a  slight  accumulation  of  urinary  sediment  upon  the  sides  and  bottom 
of  the  bottle  that  rinsing  with  cold  water  had  been  insufficient  to  remove. 
In  this  sediment  bacteria  had  thrived  and  waxed  fat,  and  when  healthy 
urine  was  voided  into  the  bottle  they  soon  began  to  multiply  very  rapidly. 
Frequent  scalding  of  the  vessel  after  the  discovery  of  this  fact  obviated 
further  difficulty,  as  can  be  readily  understood  in  the  light  of  our  more 
recent  knowledge  of  the  subject. 

Foam  upon  the  Urine. — Persistent  foam  upon  the  urine — i.e.,  foam 
remaining  upon  its  surface  for  half  an  hour  or  more — is  an  indication,  as 
a  rule,  of  either  albumin  or  bile,  or  both.  Mucus  in  considerable  amount 
is  also  productive  of  persistent  foam.  This  suggests  in  a  general  way  a 
catarrhal  state  of  the  mucous  membrane  of  the  urethra,  bladder,  or  pelvis 
of  the  kidney,  or  structural  renal  disease,  and  is  a  point  well  worth 
remembering. 

Gross  Characters  of  Urinary  Sediments. — It  is  very  useful  to  be  able 
to  form  a  general  estimate  of  the  character  of  urinary  deposits  from  their 
macroscopic  appearance.  Sediments  occur  in  the  urine  very  frequently,  and 
may  be  deposited  before  its  evacuation  from  the  bladder.  This  is  often 
the  case  in  certain  forms  of  kidney  and  vesical  disease.  On  the  other  hand, 
deposits  may  appear  only  after  the  fluid  has  stood  for  a  variable  time. 
The  various  substances  constituting  urinary  sediments  may  be  insoluble 
in  the  urine  primarily,  or  they  may  be  soluble  only  in  the  warm  fluid, 
rapidly  precipitating  when  it  becomes  cool.  Still  other  sediments  result 
from  chemic  changes  occurring  with  greater  or  less  rapidity  after  the 
evacuation  of  the  fluid. 

A  deposit  of  a  fawn  color  and  of  more  or  less  powdery  consistence, 
unless  mixed  with  mucus,  appearing  in  the  cold  urine,  but  dissolving  when 


URINARY    SEDIMENTS.  17 

heated,  consists  of  urates  of  sodinm  or  ammoniiim,  or  both.  Cystin  is  an- 
other, but  much  rarer,  deposit  of  a  similar  color,  not  dissolved  by  heat, 
and  only  slowly  acted  upon  by  alkalies.  A  heavy,  red,  sandy  deposit  at 
the  bottom  of  the  vessel  is  composed  of  uric  acid.  This  is  dissolved  both 
by  nitric  acid  and  alkalies.  Blood-corpuscles  may  form  a  reddish  deposit 
at  the  bottom  of  the  fluid,  the  peculiar  color  giving  some  idea  of  the  char- 
acter of  the  deposit.  A  whitish  deposit  not  soluble  in  the  heated  urine,  and 
often  deposited  by  heating  previously  clear  urine,  is  composed  of  the  earthy 
salts — triple  phosphates,  phosphate  of  lime,  and  oxalate  of  lime.  The 
oxalate  of  lime  and  phosphates  are  difiEerentiated  by  adding  acetic  acid, 
the  latter  deposit  clearing  up,  while  the  former  does  not.  A  creamy-white, 
ropy,  or  flocculent  sediment  is  probably  mucus;  a  yellow  deposit  forming 
a  sort  of  jelly  with  liquor  potassse  is  usually  composed  of  pus  or  muco-pus. 
Long,  whitish  strings  or  filaments — tripper-fdden — often  occur  as  a  con- 
sequence of  stricture  or  chronic  urethritis. 

The  various  urinary  deposits  require  special  consideration. 


Fig.  1. — Ammonium-urate  crystals. 

Ur^ea  is  one  of  the  most  important  substances  for  our  consideration 
in  connection  with  the  excreted  solids  of  the  urine.  It  does  not  occur  alone 
in  the  form  of  deposits  because  of  its  extreme  solubility.  The  quantity  of 
urea  excreted  during  twenty-four  hours  is  the  best  criterion  of  the  excretory 
activity  of  the  kidneys,  and  is  important  in  its  relations  to  both  medicine 
and  surgery.  If  in  any  particular  case  the  amount  of  urea  excreted  has 
been  determined,  the  surgeon  is  in  a  position  to  decide  whether  the  patient 
is  in  danger  of  so-called  uremia  or  not.  This  question  demands  most  care- 
ful consideration  in  connection  with  operations  upon  and  diseases  of  the 
genito-urinary  tract. ^ 

Urea  represents  the  ultimate  product  of  tissue-metabolism,  its  amount 


^  It  is  to  be  remembered,  however,  that,  although  urea  is  a  very  imjiortant 
lu'inary  solid,  it  normally  represents  chiefly  muscle-waste,  and  its  amount  is  not 
necessarily  regulated  by  the  condition  of  the  kidneys.  When  produced  in  small 
amount  its  excretion  is  likewise  small. 


18  UEIXALYSIS    IN    ITS    SUEGICAL    KELATIOXS. 

depending  (1)  upon  the  amount  of  proteids  ingested,  (2)  upon  the  actiyity 
of  physiochemic  transformation  of  proteids  after  digestion  and  absorption, 
(3)  upon  the  actual  amount  of  waste  of  the  fixed  tissues,  and  (4)  upon 
the  degree  of  functional  activity  of  the  kidneys. 

In  all  diseases  in  which  fever  is  a  symptom  the  excretion  of  urea  is 
increased.  Diseases  of  the  liver  modify  the  amount  of  urea,  inasmuch  as 
it  is  the  organ  in  which  the  physiochemic  changes  resulting  in  the  forma- 
tion of  urea  are  most  energetic.  In  hepatic  abscess,  and  in  cancer  of  the 
liver,  a  notable  diminution  of  urea  is  observable.  The  various  forms  of 
surgical  disease  of  the  kidney  itself  generally  cause  a  diminution  in  the 
excretion  of  urea. 

For  ordinary  purposes  it  is  not  necessary  to  resort  to  the  intricacies 
of  quantitative  urinalysis  to  determine  with  sufficient  accuracy  for  practical 
purposes  the  amount  of  excreted  urea.  If  the  total  quantity  of  urine  be 
normal  or  nearly  so,  and  the  specific  gravity  of  the  urine  is  not  appreciably 
lowered,  it  may  be  inferred,  if  sugar  is  not  present,  that  a  sufficient  amount 
of  urea  is  being  excreted  to  fulfill  the  needs  of  the  economy.  If  the  specific 
gravity  is  low,  but  there  is  a  compensating  increase  in  the  total  amount 
of  excreted  urea,  we  are  also  justified  in  believing  that  there  is  no  imminent 
danger  of  toxemia.  Due  consideration  must,  hoAvever,  be  given  to  the 
amount  of  fluid  ingested,  and  the  amount  and  quality  of  the  food. 

Uric  acid  was  formerly  thought  to  be  the  characteristic  element  in  the 
composition  of  urinary  calculi;  hence  it  was  called  lithic  acid.  Since  its 
discovery,  more  than  one  hundred  years  ago,  it  has  been  shown  to  bear  an 
important  relation  to  gout,  and  incidentally  it  has  been  demonstrated  that 
a  gouty  or  lithic  condition  of  the  blood  is  the  foundation  of  many  cases 
of  urinary  calculi.  Garrod  in  particular  has  dwelt  upon  the  association  of 
uricemia  and  gout,  and  has  shown  that  an  excess  of  uric  acid  is  present  in 
the  blood  during  an  attack  of  that  disease. 

Uric  acid  has  been  described  as  a  midproduct  of  tissue-metabolism. 
It  is  the  result  of  imperfect  oxidation  of  those  nitrogenized  elements  of 
the  food  which  should  be  converted,  on  the  one  hand,  into  substances 
ready  for  assimilation  by  the  tissues,  and,  on  the  other,  into  urea.  Uric 
acid  bears  an  important  relation  to  the  surgical  affections  of  the  genito- 
urinary tract,  the  severity  of  all  inflammatory  affections  being  to  a  certain 
extent  dependent  upon  its  amount,  not  only  in  the  urine,  but  in  the  blood 
— not  that  the  acidity  of  the  urine  is  dependent  upon  uric  acid,  but  because 
urine  containing  an  excess  of  this  substance  is  heavy  and  irritating  by  virtue 
of  the  mechanic  effects  of  the  uric-acid  crystals  themselves.  The  intimate 
association  of  uric  acid  and  the  urates  with  urinary  calculus  is  familiar  to 
every  practical  physician  and  surgeon. 

The  close  association  of  uricemia  with  gout  is  well  illustrated  by  the 
fact  that  the  so-called  gouty  deposits,  or  tophi,  which  occur  in  the  joints, 
the  cartilages  of  the  ear,  and  in  the  tubuli  recti  of  the  kidney  are  com- 


UEINAEY    SEDIMENTS.  19 

posed  of  sodium  urate.  Uric  acid  requires  for  its  solution  about  15,000 
parts  of  water,  in  this  respect  differing  markedly  from  urea,  which  is  very- 
soluble.  Thus,  when  the  urine  is  very  concentrated,  and  the  amount  of 
water  much  below  the  normal  standard,  the  deposition  of  uric  acid  is  likely 
to  occur.  Uric  acid  and  the  urates  may  vary  in  quantity  by  modifications 
of  diet.  Uric  acid,  when  deposited  in  the  urine  in  a  free  state,  resembles 
brick-dust  or  red  pepper. 

Oxalic  acid  in  the  urine  in  the  form  of  calcium  oxalate — oxaluria — 
has  given  rise  to  considerable  controversy  regarding  its  origin.  It  has  been 
generally  held  that  oxalate  of  calcium  as  a  urinary  deposit  is  a  derivative 
of  the  decomposition  of  uric  acid  after  its  formation,  thus  implying  that 
the  crystals  of  oxalate  of  lime  signify  only  an  excess  of  uric  acid.  It  has 
been  assumed  by  those  who  accept  this  view  that  oxalic  acid  {i.e.,  oxalate 
of  lime)  bears  the  same  relation  to  uric  acid  that  uric  acid  does  to  urea. 
This  hypothesis  implies  that  the  process  of  oxidization  if  stopped  at  a  cer- 
tain point  produces  oxalic  acid;    a  little  further  on,  uric  acid;    and,  when 


Fig.  2. — Uric-acid  crystals. 

perfected,  urea.-  Per  contra,  in  order  to  obtain  oxalic  acid  from  uric  acid 
it  is  necessary  to  oxidize  it  more  completely.  The  determination  of  the 
precise  conditions  producing  oxalic  acid  in  the  tissues  is  necessarily  a  very 
difficult  matter.  In  spite  of  all  the  theories  that  have  been  advanced, 
it  can  only  be  said  that  an  excess  of  oxalic  acid  in  the  blood — oxalemia — 
and  of  calcium  oxalate  in  the  urine  result  from  certain  undetermined  per- 
versions and  modifications  of  tissue-metabolism. 

A  &mall  quantity  of  oxalic  acid  is  present  normally  in  the  blood,  and 
is  discoverable  in  the  form  of  calcium  oxalate  in  the  urine  as  a  consequence 
of  numerous  circumstances.  Thus,  its  presence  may  be  due  to:  1.  Inges- 
tion of  an  excessive  quantity  of  food-substances  containing  calcium  oxalate, 
— e.g.,  certain  vegetable  matters,  such  as  rhubarb,  tomatoes,  turnips,  and 
onions,  rhubarb  containing  a  large  quantity  of  this  substance.  2.  Imper- 
fect oxidation  of  starchy  and  fatty  food-materials,  which  before  their 
final  transformation  into  HoO  and  CO,  pass  through  transformations  in 
which  they  present  themselves  as  organic  acids:  i.e.,  oxalic,  lactic,  butyric, 
and  glycocholic   acid.      3.  Increase   in   the   physiochemic   activity   of   the 


20  t'EIXALYSIS    IX    ITS    SUEGICAL    EELATIOXS. 

tissues.  This  involves  the  question  of  exercise  and  hypermetabolism  of 
tissue  cliie  to  certain  nervous  influences.  4.  It  has  been  asserted  that  oxalate 
of  lime  may  be  derived  from  the  mucus  of  the  genito-urinary  mucosa. 
The  only  way  that  this  could  occur  would  be  through  urinary  decomposi- 
tion excited  by  the  mucus.  This  theory  of  the  origin  of  oxalic  acid, 
although  advanced  by  an  excellent  authority  (Meckel),  is  evidently  purely 
theoretic.  5.  An  excess  of  acids  in  the  blood  and  tissues  as  a  result  of  buty- 
ric and  lactic  fermentation  in  the  alimentary  canal.  These  substances  being 
absorbed,  are  not  completely  oxidized  or  transformed  into  C0„,  and,  as  a 
consequence,  the  midiDrodiict,  oxalic  acid,  is  formed. 

The  presence  of  oxalic  acid  has  been  claimed  by  certain  observers  to 
hear  a  certain  relation  to  diabetes.  Thus,  Cantani  asserts  that  he  has 
noticed  an  alternation  of  calcium  oxalate  and  sugar  in  the  urine.  Fiir- 
bringer  discovered  oxalic  acid  in  the  sputum  of  a  patient  suffering  from 
diabetes  mellitus. 

The  excretion  of  oxalic  acid  in  the  urine  has  received  considerable  at- 
tention.   When  present  in  excess  it  has  been  supposed  to  signify  perturba- 


Jk0.^O 


Fig.  3. — Calcium-oxalate  crystals. 

tion  of  tissue-waste,  and  has  been  described  as  a  distinct  disease — oxaluria. 
While  the  presence  of  the  crystals  of  oxalate  of  lime  in  the  urine  may 
unquestionably  produce  irritation  of  the  mucous  membrane  of  the  genito- 
urinary tract,  with  frequent  micturition  and  pain  in  the  back,  the  author 
believes  that  the  importance  of  the  substance  has  been  greatly  overesti- 
mated. It  is  hardly  fair  to  ascribe  a  severe  pain  in  the  back,  accompanied 
by  an  excess  of  calcium  oxalate  in  the  urine,  to  irritation  produced  by  the 
crystals  in  all  cases,  for  the  relation  of  cause  and  effect  is  difficult  to 
demonstrate.  Such  diagnoses  are  apt  to  lead  to  a  confusion  of  propter  and 
post:  in  other  words,  the  pain  and  oxaluria  may  both  be  dependent  upon 
actual  renal  disturbance  or  upon  nervous  derangement. 

Calcium  oxalate  is  associated  with  one  form  of  urinary  calculus  (the 
mulberry)  which  is  composed  almost  or  quite  entirely  of  that  substance. 
Pronounced  oxaluria  is  usually  associated  with  digestive  disturbance  and 
nervous  depression. 

Phosphoric  acid  in  the  form  of  the  phosphates  is  a  frequent  and  im- 
portant  urinary   deposit.      Triple   phosphates — ammonio-magnesian   phos- 


GLYCOSUEIA   AS    A    SYMPTOM    OF    GENITO-UKIXARY    DISEASE. 


21 


phates — are  most  frequent^,  and  calcium  phosphate  the  rarest  form.  The 
normal  acidity  of  the  urine  is  dependent  upon  the  biphosphate,  or  acid 
phosphate,  of  soda.  Phosphates  are  not  deposited  so  long  as  the  urine 
remains  acid,  but  immediately  it  becomes  alkaline  a  deposit  occurs,  whether 
the  phosphoric  acid  in  the  urine  be  in  excess  or  not.  The  principal  surgical 
importance  of  the  phosphates  is  their  relation  to  urinary  calculus,  hyper- 
trophy of  the  prostate,  chronic  cystitis,  and  pyelitis.  Whenever  the  urine 
decomposes  as  a  consequence  of  an  excess  of  mucus  or  from  prolonged 
retention,  a  deposit  of  phosphates  occurs.  If  a  foreign  body  be  present, 
this  deposition  of  phosphates  occurs  about  it,  and  eventually  solidifies, 
forming  a  calculus  about  the  nucleus;  thus,  it  may  form  about  a  small 
quantity  of  uric  acid  or  calcium  oxalate  that  has  come  down  from  the 
kidney,  a  clot  of  mucus,  or  a  foreign  body  introduced  into  the  bladder 
from  without.  The  addition  of  an  acid  to  phosphatic  urine  clears  it  up 
immediately. 

Xaniliic  oxid,  or  i-anthin,  presents  itself  in  the  urine  as  a  very  rare 


Fig.  4. — Triple-phosphate  crystals. 


form  of  urinary  calculus.     Cases  have  been  reported  by  Langenbeck  and 
Bence  Jones.    Such  cases  have  been  seen  in  young  subjects.^ 

Glycosuria  as  a  Symptom  of  Genito-Ueixaey  Disease. — In  an 
article  published  some  time  since  the  author  called  attention  to  glycosuria 
as  an  occasional  result  of  the  reflex  irritation  incidental  to  surgical  diseases 
of  the  genito-urinary  tract,  especially  phimosis  and  stricture.-  The  follow- 
ing cases  are  illustrative  of  this  exceedingly  interesting  and  important  point: 

Case  1. — E.  B.,  male,  aged  7  years,  had  been  afflicted  with  glycosuria — which 
had  been  diagnosed  as  diabetes  mellitus — for  some  seven  months.     During  this  time 


^  It  is  probable  that  xanthin  and  its  derivatives  bear  a  more  important  relation 
to  urinary  toxemia  than  is  generally  supposed— more  important,  perhaps,  than  urea. 
The  coloring  matter  of  the  urine  and  the  potassium  salts  are  also  important  factors 
in  urinary  toxemia. 

^  Western  Medical  Review,  October,  1897. 


23  UEINALYSIS    IN    ITS    SUEGICAL    EELATIONS. 

the  child  had  been  under  the  care  of  several  exceptionally-competent  medical  men, 
and  had  seemed  at  times  to  be  improving  under  treatment.  The  sugar  in  the  urine 
had,  however,  at  no  time  wholly  disappeared,  and  at  the  time  the  author  was  con- 
sulted the  glycosuria  was  more  marked  than  it  had  been  for  several  months — this 
in  spite  of  careful  treatment  and  an  antidiabetic  diet.  There  were  practically  no 
suggestions  to  offer  regarding  the  medical  treatment  of  the  case,  and  the  child's 
parents  were  so  infornied.  Some  improvement,  however^  resulted  under  the  con- 
tinuance of  the  treatment  to  which  the  case  had  already  been  subjected,  but  the 
glycosuria  not  only  did  not  disappear,  but  relapsed  from  time  to  time  after  apparently 
marked  improvement.  The  possible  etiologic  relation  of  genital  irritation  to  the 
glycosuria  was  not  at  first  suspected.  The  father  of  the  patient,  however,  finally 
called  attention  to  the  fact  that  the  child  appeared  to  be  troubled  with  irritation  about 
the  penis.  Examination  showed  an  adherent  prepuce  and  balanitis.  Circumcision  was 
soon  followed  by  improvement  in  the  condition  of  the  urine,  and  within  two  months 
the  glycosuria  had  completely  disappeared  and  the  patient  was  entirely  well,  there 
being  no  recurrence  of  the  diabetic  symptoms  during  the  year  that  the  child  was  subse- 
quently under  observation. 

Case  2. — A  second  very  similar  case  came  under  the  author's  care  some  months 
later.  A  boy,  15  years  of  age,  had  manifested  diabetic  symptoms  for  about  three 
months.  Bulimia  and  thirst  were  especially  marked,  and  the  quantity  of  urine  greatly 
increased.  With  the  case  previously  recorded  in  mind,  possible  sources  of  reflex  genital 
iri'itation  were  at  once  looked  for.  A  stenosed  and  adherent  prepuce  and  a  greatly- 
contracted  meatus  were  found.  These  conditions  were  corrected  and  the  patient  put 
upon  arsenite  of  bromin  and  the  regulation  diet.  The  ease  rapidly  improved,  and 
four  months  later  the  last  trace  of  sugar  had  disappeared  from  the  urine.  The 
patient  has  since  remained  perfectly  well,  and,  as  over  two  years  have  elapsed  with- 
out recurrence  of  glycosuria,  the  cure  is  probably  permanent. 

The  pertinence  of  the  foregoing  clinical  observations  may  be  questioned 
on  the  ground  that  the  ordinary  dietetic  and  medicinal  measures  of  treat- 
ment were  em^Dloyed.  Considering,  however,  the  rapid  and  fatal  course  of 
diabetes  in  young  children,  in  spite  of  the  best  of  treatment,  the  assumption 
is  warrantable  that  the  genito-urinary  irritation  bore  a  causal  relation  to  the 
diabetes  in  these  cases.  The  result  of  the  surgical  treatment  Avould  seem 
to  corroborate  this  view. 

The  following  case  in  an  adult  is  quite  suggestive: — 

Case  3. — A  man,  aged  30,  consulted  the  author  regarding  an  irritable  stricture 
of  the  deep  urethra.  Urinalysis  showed  marked  glycosuria.  There  were  no  diabetic 
symptoms  of  a  general  character.  After  the  irritability  of  the  stricture  had  been 
allayed  by  suitable  treatment,  dilation  was  begun  and  successfully  carried  out.  As 
the  local  difficulty  improved  the  glycosuria  gradually  diminished  and  finally  dis- 
appeared.    A  year  later  there  had  been  no  recun-ence. 

M,  L,  Harris  has  furnished  the  author  with  notes  of  a  case  that  is  perti- 
nent to  the  foregoing  clinical  observations: — 

Case  4. — A  man,  35  years  of  age,  had  had  gonorrhoea  some  years  before  coming 
under  observation.  When  first  seen  the  patient  had  been  receiving  treatment  for 
diabetes  mellitus  for  some  time.  He  presented  the  usual  symptoms.  The  urine  was 
highly  saccharin  and  passed  in  large  amount.  Thirst  excessive  and  bulimia  marked. 
No  particular  degree  of  emaciation.     Pain  and  difficulty  in  urination  developed  and 


ORGANIZED    DEPOSITS.  23 

the  patient  was  referred  for  surgical  treatment.  Urethral  exploration  revealed  a 
very  sensitive,  rather  soft  stricture  of  the  membranous  urethra,  which  admitted  Xo. 
12  French.  The  stricture  yielded  easily  to  gradual  dilation,  and  with  the  disappear- 
ance of  the  stricture  all  traces  of  sugar  disappeared  from  the  urine,  as  well  as  all 
symptoms  of  the  diabetes. 

Oeganized  Deposits — Chaeactee  of  the  TJeine  in  Special  Con- 
ditions.— Albumin  in  the  urine,  whether  associated  with  the  ordinary 
forms  of  nephritis  or  not,  is  quite  constant  in  certain  surgical  diseases  of 
the  genito-urinary  tract.  For  practical  purposes  urinary  albumin  may  be 
divided  into  serum-albumin  and  pus-albumin.  It  is  important  to  difEer- 
entiate  the  two,  for  there  is  a  wide  variation  in  prognosis  according  to 
the  origin  of  the  albumin.  On  the  one  hand,  the  albumin  is  due  to  renal 
disease  of  a  serious  and  probably  incurable  character,  while,  upon  the  other, 
its  presence  depends  upon  the  presence  in  the  urine  of  certain  inflammatory 
products  of  local  disease.  It  is  impossible  to  difEerentiate  the  two  forms 
of  albumin  by  simple  chemic  examination.  When  there  is  no  renal  disease 
the  case  may  be  diagnosed  negatively  by  the  constant  absence  of  casts  of 
the  urinary  tubuli  and  upon  the  symptoms  and  clinical  history  of  the  case. 
If,  on  the  other  hand,  acute  or  chronic  suppurative  disease  of  the  genito- 
urinary tract  co-exists  with  morbus  Brightii,  it  is  difhcult  to  determine  the 
precise  amount  of  albumin  dependent  upon  each  cause.  We  must  be  guided, 
to  a  certain  extent,  by  the  amount  of  excreted  solids,  which  is  a  criterion  of 
the  functional  activity  of  the  kidneys,  and  the  specific  gravity  of  the  urine 
after  all  pus  has  been  removed.  In  the  majority  of  instances  in  which  pus 
is  present  a  fair  estimate  of  the  condition  of  the  kidneys  may  be  formed 
by  decanting  the  supernatant  fluid  from  the  purulent  deposit,  and  after 
filtration  subjecting  it  to  chemic  examination.  When  the  pus  is  dependent 
upon  inflammation  of  the  bladder  or  urethra,  these  parts  may  be  thoroughly 
freed  from  pus  by  irrigation,  after  which  a  small  quantity  of  urine  is  allowed 
to  accumulate  and  then  withdrawn  and  examined.  The  difference,  or 
otherwise,  in  the  amount  of  albumin  in  the  first  and  last  specimens  is  a  fair 
criterion  of  the  condition  of  the  kidneys. 

Albumin  may  be  found  in  the  urine  in  surgical  kidney  with  or  with- 
out co-existent  pyelitis,  in  cystitis,  vesical  cysts,  enlarged  prostate,  gonor- 
rhea, gleet,  and  hemorrhage  from  any  portion  of  the  genito-urinary  tract. 

Albumin  is  likely  to  be  found  in  that  peculiar  form  of  renal  disease 
secondary  to  prolonged  and  wasting  suppurative  processes  in  various  por- 
tions of  the  body,  particularly  those  involving  the  bones,  of  which  caries 
of  the  spine  and  hip-joint  are  familiar  examples.  This  is  associated  with 
a  similar  lardaceous  deposit  in  the  liver,  and  perhaps  other  viscera,  and 
is  known  as  the  amyloid,  or  waxy,  kidney.  It  is  to  be  considered  as  a  sur- 
gical affection  of  the  kidney — although  not  amenable  to  surgical  methods 
of  relief — because  of  its  occurrence  as  a  secondary  feature  of  surgical  dis- 
eases elsewhere  than  in  the  genito-urinarv  tract.     Whenever  albumin  is 


24  UKINALYSIS    IN    ITS    SUEGICAL    EELATIONS. 

present  in  the  urine  and  no  tube-casts  can  be  found,  after  repeated  exami- 
nations with  the  microscope,  it  is  reasonable  to  suppose  that  the  secreting 
structure  of  the  kidney  is  free  from  serious  disease — from  the  surgeon's 
stand-point,  at  least. 

Blood  is  found  in  the  urine  in  a  number  of  distinct  and  separate 
affections  of  the  genito-urinary  tract.  The  various  conditions  giving  rise 
to  its  presence  will  be  discussed  in  detail  in  a  su.bsequent  special  chapter 
on  hematuria.    In  a  general  way  its  origin  may  be: — 

1.  Local  disease  or  injury  of  any  portion- of  the  genito-urinary  mucous 
membrane:  for  example,  external  traumatism,  laceration  by  a  passing  cal- 
culus or  the  movements  of  a  large  vesical  calculus,  renal  hyperemia, 
acute  Bright's  disease,  drugs,  parasitic  disease,  cancer,  sarcoma,  and  tuber- 
culosis. 

2.  Peculiar  conditions  of  depravity  or  disorganization  of  the  blood: 
such,  for  example,  as  is  met  with  in  scorbutus,  purpura  hemorrhagica,  per- 
nicious malarial  infection,  and  typhus  fever. 

3.  Perturbation  of  the  capillary  circulation  of  the  renal  tissue,  such 
as  is  sometimes  met  with  in  simple  intermittent  fever,  or  as  a  result  of 
certain  peculiar  impressions  made  through  the  emotions  upon  the  vaso- 
motor filaments  of  the  sympathetic. 

4.  And,  most  rarely,  simple  passive  hyperemia  incident  to  obstructive 
cardiac  lesion. 

There  is  obviously  no  constancy  in  the  amount  of  blood  present  in  the 
urine  in  hematuria.  The  color  of  the  urine  varies  from  a  slight  foggy  or 
smoky  hue  to  one  closely  approximating  pure  blood.  In  some  cases  the 
blood  is  fluid,  while  in  others  coagula  of  greater  or  less  size  are  present, 
this  feature  varying  with  the  activity  and  source  of  the  hemorrhage.  The 
amount  of  blood  necessary  to  give  a  decided  red  or  black  color  to  the  urine 
varies  somewhat.  Much  depends  upon  the  degree  of  freshness  of  the  blood 
and  upon  the  depth  of  the  color  of  the  urine  prior  to  its  admixture  Avith 
the  blood.  In  some  cases  a  very  slight  hemorrhage  from  any  part  of  the 
genito-urinary  tract  imparts  an  intensely-red  color  to  the  urine. 

Ralfe  has  made  some  practical  experiments  respecting  this  point.  He 
remarks  as  follows: — 

In  some  of  the  experiments  I  made  in  1873  at  the  laboratory  of  Charing  Cross 
Hospital,  and  published  in  the  Lancet,  I  found  that  only  1  part  of  blood  gave  a 
decided  smoky  tint  to  1500  parts  of  normal  urine,  while  1  part  in  500  gave  a  briglit- 
cherry  color.  Considerable  hemorrhages,  therefore,  are  best  judged  by  the  amount 
of  coagula  rather  than  by  mere  intensity  of  color. 

In  some  instances  blood  is  present  in  the  urine  in  its  normal  or  formed 
condition,  blood-corpuscles  being  recognizable  microscopically — hematuria. 
Less  frequently  the  corpuscles  are  disorganized,  nothing  but  their  coloring 
matter  being  present— hemoglobinuria  or  hematinuria.  In  general,  the 
former  condition  is  indicative  of  a  distinct  solution  of  continuity  of  some 


OEGANIZED    DEPOSITS.  25 

portion  of  the  genito-iirinary  tract,  the  blood  being  nsnally  of  normal  com- 
position and  consistency;  while  in  the  latter  there  may  be  no  solution  of 
continuity  in  the  genito-nrinary  mncous  membrane,  but  aplasticity  and  dis- 
organization of  the  blood,  permitting  the  fluid  to  transude  freely  through 
the  walls  of  the  capillary  blood-vessels  and  appear  in  the  urine.  If  the 
blood-corpuscles  escape  under  such  circumstances,  they  are  of  such  low 
vitality  that  they  are  easily  broken  down  and  quickly  disappear. 

Bile  in  the  urine  is  of  importance  only  in  relation  to  those  diseases  of 
the  liver  which  are  amenable  to  surgical  interference:  for  example,  hepatic 
abscess  and  some  cases  of  biliary  calculi. 

Chyle  in  the  urine  (chyluria)  is  a  very  rare  phenomenon.  In  such 
cases  the  urine  has  much  the  appearance  of  milk,  sometimes  jnixed  with 
blood.  After  the  urine  has  stood  for  some  time  a  Jelly-like  clot  forms. 
The  presence  of  chyle  in  such  cases  is  probably  due  to  a  lesion  of  some 
kind  affecting  the  renal  lymphatic  capillaries.  A  few  recorded  cases  of 
chronic  chyluria  have  been  found  to  depend  upon  the  presence  of  the 
Filaria  sanguinis  hominis:   a  rare  and  peculiar  form  of  ^^arasite. 

The  admixture  of  fatty  material  with  the  urine  sometimes  gives  an 
appearance  resembling  chyluria.  Ealfe  reports  a  case  of  this  kind  occur- 
ring in  a  patient  dying  of  acute  diabetic  coma  (acetonemia). 

Fibrin  never  appears  in  the  urine  excepting  as  a  secondary  condition 
in  chyluria,  in  which  it  forms  the  jelly-like  clot  already  alluded  to,  and  in 
hematuria,  in  which  disease  casts  of  various  portions  of  the  urinary  tract 
are  often  found. 

Mucus  appears  in  normal  urine,  sometimes  immediately,  and  almost 
always  within  a  few  hours  after  it  has  been  voided.  It  forms  in  little 
clouds  that  finally  settle  to  the  bottom  of  the  vessel.  Under  the  microscope 
we  find  in  these  cloudy  deposits  epithelial  cells,  mucus-corpuscles,  and 
coagula  of  mucus.  In  urine  from  the  female  there  may  be  an  admixture 
of  blood,  mucus,  and  pus-corpuscles  from  the  vagina,  dependent  upon  a 
combination  of  menstrual  fluid  and  leucorrheal  secretion.  The  urinary 
mucus  is  increased  in  amount  by  different  diseases  of  the  genito-urinary 
tract.  For  example,  in  vesical  catarrh  its  amount  is  a  fair,  but  not  accu- 
rate, criterion  of  the  condition  of  the  genito-urinary  mucous  membrane. 
In  some  instances  mucus  presents  itself  in  the  form  of  longitudinal  strias 
resembling  hyaline  casts,  but  distinguished  from  the  latter  by  their  irregu- 
lar outline  and  their  comparatively  greater  breadth  and  branched  form. 
Mucus  may  be  removed  from  the  urine  by  adding  to  the  cold  fluid  acetic 
acid, — which  separates  the  mucus  in  the  form  of  a  flaky  deposit, — followed 
by  filtration,  which  clears  the  urine  completely.  Turbidity  resulting  from 
boiling  consists  either  of  albumin  or  phosphates;  the  addition  of  nitric 
acid  increases  the  turbidity  in  the  case  of  the  former,  and  clears  the  urine 
in  the  case  of  the  latter. 

Pyuria. — Pus-corpuscles  are  found  in  the  urine  in  chronic  inflamma- 


36  UEINALYSIS    IN    ITS    SIJKGICAL    EELATIONS. 

tion  of  the  genito-urinary  mucosa.  It  is  ordinarily  impossible  to  dis- 
tinguish them  microscopically  from  the  mucus-corpuscle  or  chyle-corpuscle. 
According  to  Peyer,  "single  pus-corpuscles"  occur  in  almost  every  urine, 
especially  that  of  women;  but  as  a  matter  of  fact,  the  corpuscles  described 
by  Peyer  are  simply  mucus-corpuscles.  The  clinical  features  of  each  par- 
ticular case  must  be  taken  into  consideration  in  the  differentiation  of  pus 
and  mucus,  as  the  microscope  alone  will  not  serve  to  distinguish  them. 
Whenever  the  form  of  corpuscle  presented  by  mucus  and  pus  occurs  in 
large  numbers  in  the  urine,  the  presence  of  pus  may  be  inferred.  Pus  is 
invariably  an  indication  of  acute  or  chronic  inflammation  of  some  portion 
of  the  genito-urinary  system.  Pus-corpuscles  are  about  double  the  size  of 
blood-corpuscles,  are  opaque  and  finely  granular,  this  granular  appearance 
serving  to  conceal  their  nuclei,  which,  however,  become  visible  on  the 
addition  of  acetic  acid.  The  pus-corpuscles  may  be  crenated  or  notched 
in  appearance.  When  the  urine  is  strongly  ammoniacal,  they  dissolve  to  a 
certain  extent  and  coalesce  into  a  mass,  losing  their  form,  so  that  the 
microscope  shows  only  their  nuclei.  When  urine  containing  pus  is  freshly 
voided,  the  pus-corpuscles  may  present  under  the  microscope  the  peculiar 
ameboid  movement  of  the  leucocyte. 

Blood-corpuscles  appear  under  the  microscope  usually  in  the  form  of 
pale-reddish  or  amber-colored,  biconcave  disks.  Their  form  varies  according 
to  the  manner  in  which  they  lie  in  the  visual  field.  When  they  lie  upon 
edge  they  have  a  sort  of  biscuit  form,  but  when  lying  upon  their  flat  surfaces 
they  present  a  dark  center  with  a  lighter  areola  about  it,  and  are  apparently 
round  or  nearly  so.  When  they  remain  in  the  urine  for  a  long  time,  and 
particularly  if  the  urine  becomes  ammoniacal,  they  become  paler  and  more 
globular,  and  finally  are  completely  dissolved,  liberating  their  pigment. 

Epithelium  is  usually  found  in  normal  urine,  and  is  indicative  of  the 
same  changes  as  occur  in  the  stratum  corneum  of  the  skin,  viz.:  the 
shedding  of  effete  epithelium.  This  shedding  of  epithelium  is  not  abundant 
under  normal  circumstances.  In  the  presence  of  disease,  however,  it  is 
increased,  and  we  therefore  find,  in  cases  in  which  there  is  an  abundance 
of  muco-pus  or  pus,  an  increased  quantity  of  epithelium  the  form  of  which 
depends  upon  the  site  of  the  morbid  process.  In  case  of  inflammation  of 
the  renal  tubuli  and  urethra  the  epithelial  cells  are  rounded.  The  epi- 
thelial cells  from  the  vagina  and  bladder  are  of  the  pavement  variety,  often 
hexagonal  in  form,  nucleated,  and  not  to  be  differentiated  from  each  other. 
Caudate  epithelium  originates  usually  in  the  renal  pelvis;  this  form  of  epi- 
thelium is  sometimes  spindle-shaped.  In  some  instances  of  severe  inflam- 
mation about  the  neck  of  the  bladder  caudate  epithelial  cells  are  exfoliated. 
Thus,  Peyer  describes  a  case  in  which  a  large  quantity  of  caudate  epithelium 
was  thrown  ofl  after  cauterization  of  the  deep  urethra. 

Casts  in  the  urine  bear  a  more  important  relation  to  the  medical  dis- 
eases of  the  kidney  than  to  those   of  a  strictly  surgical  character.     We 


CLINICAL    FEATURES    OP   THE    UEIXE   IN    VARIOUS    DISEASES.  27 

may,  however,  find  them  in  nephritis  secondary  to  surgical  diseases  of  the 
genito-nrinary  tract  and  in  renal  hemorrhage.  They  may  appear  in  the 
form  of  epithelial  cylinders,  consisting  of  an  exfoliation  en  masse  of  the 
epithelial  lining  of  the  renal  tubuli.  Hyaline  cylinders  or  granular  casts 
may  be  met  with,  according  to  the  form  and  stage  of  the  morbid  change 
in  the  secretory  structure  of  the  kidney.  Blood-casts  and  fibrin-casts  occur 
as  a  consequence  of  renal  hemorrhage.^ 

Clinical  Features  of  the  Urine  in  Various  Diseases. — The  con- 
dition of  the  urine  in  the  special  diseases  of  the  genito-urinary  tract  is 
what  most  concerns  the  surgeon. 

Injuries  of  the  urethra,  prostate,  bladder,  kidney,  and  testis  may  give 
rise  to  blood  in  the  urine.  Hematuria  from  these  accidents  will  be  de- 
scribed in  detail  in  connection  with  the  special  discussion  of  that  subject. 
The  appearance  of  the  urine  necessarily  varies  according  to  the  amount  of 
hemorrhage  and  its  location.  When  the  hemorrhage  is  from  the  urethra 
the  blood  is  apt  to  appear  in  the  form  of  a  long,  pencil-shaped  coagulum, 
the  discharge  of  which  is  followed  by  a  flow  of  fluid  blood.  The  bulk  of 
the  blood  appears  in  the  first  portion  of  the  urine,  the  midportion  being 
comparatively  clear,  but  a  certain  amount  of  almost  pure  blood  being  ex- 
truded at  the  end  of  the  act  of  micturition  as  it  is  forced  out  of  the  injured 
part  by  the  contraction  of  the  cut-off  and  accelerator-urinee  muscles.  The 
blood  in  these  cases  is  quite  dark  in  the  coagulum,  but  is  of  a  bright 
arterial  hue  as  admixed  with  the  urine  and  following  the  act  of  micturition. 
When  the  prostate  is  involved,  the  amount  of  blood  in  the  urine  may  be 
small  and  escape  in  the  form  of  a  fusiform  clot,  or  there  may  be  consider- 
able blood  diffused  throughout  the  fluid.  In  such  cases,  also,  the  con- 
traction of  the  cut-off  muscle  squeezes  out  a  certain  quantity  of  nearly 
pure  blood  at  the  end  of  the  act  of  micturition.  Hemorrhage  from  the 
bladder  may  give  rise  to  clots  in  the  urine,  sometimes  of  considerable  size, 
and  where  the  hemorrhage  forms  a  coagulum  in  the  bladder  this  will,  when 
broken  up,  give  rise  to  a  large  amount  of  dehris  of  coagulated  blood.  When 
the  urine  is  voided  soon  after  the  occurrence  of  the  vesical  hemorrhage, 
its  color  is  comparatively  bright,  but  when  it  remains  in  the  bladder  for  a 
considerable  time  it  becomes  darker  in  color.  When  the  kidneys  are  in- 
volved, the  blood  is  apt  to  be  uniformly  diffused  through  the  urine  and  to 
impart  a  quite  dark,  smoky  color.  The  urine  may  be  perfectly  opaque  in 
any  case  of  genito-urinary  hemorrhage,  this  being  entirely  dependent  upon 
the  amount  of  blood. 

The  special  points  in  differential  diagnosis  of  the  source  of  the  hemor- 
rhage will  be  discussed  in  the  chapter  on  hematuria. 


^The  intimate  relation  of  casts  to  muscular  and  cardiac  overstrain,  and  to 
transitory  vicarious  renal  strain  from  exposure  to  cold  or  rapid  temperature  fall,  is  a 
new  and  fertile  field  opened  up  by  the  centrifuge. 


28  UEINALYSIS    IN    ITS    SUEGICAL    EELATIONS. 

Blood  may  apjDear  in  the  urine  as  a  consequence  of  tranma  of  the 
testicle.  This  form  of  hematuria  is  very  rare,  excepting  as  following  the 
emission  of  bloody  semen  occurring  under  such  circumstances,  or  in  cases 
of  seminal  vesiculitis  with  semino-vesicular  hemorrhage  attending  emission. 

Acute  urethritis  gives  rise  to  pus  and  blood  in  the  urine,  the  latter 
being  sometimes  in  considerable  amount.  For  exam^Dle,  in  cases  in  which 
severe  chordee  exists  and  accidental  or  intentional  rupture  occurs,  the  blood 
is  present  in  abundant  quantity,  and  chemic  tests  develop  the  presence  of 
albumin.  There  is  usually,  also,  a  considerable  admixture  of  pavement- 
epithelium. 

Chronic  urethritis  causes  certain  peculiar  appearances  that  are  worthy 
of  consideration.  In  some  cases  the  chronic  inflammation  is  localized  at 
some  particular  point  in  the  urethra,  possibly  behind  an  organic  stricture. 
In  such  cases  we  have  the  appearance  of  the  so-called  gonorrheal  or  urethral 
threads:  tripper-fdden.  These  consist  of  little  thready  filaments  floating 
about  in  the  urine  when  freshly  voided,  and  sinking  to  the  bottom  when 
the  fluid  is  allowed  to  stand.  They  are  composed  of  mucus  and  epithelium 
rolled  up.  In  some  cases  complicated  by  spermatorrhea,  or  after  an  emis- 
sion, spermatozoa  will  be  found  mingled  with  these  threads.  Free  epi- 
thelium and  pus-corpuscles  are  also  present  in  some  cases  in  considerable 
quantity.     Gonococci  are  often  found,  and  are  of  special  significance. 

When  the  neck  of  the  bladder  is  involved  we  find  caudate  epithelium 
mixed  with  the  pus-corpuscles  and  thready  filaments.  In  some  instances 
of  chronic  urethritis  a  small  plug  of  mucus  of  a  gTayish-white  color  may 
be  found  in  the  morning  urine.  This  consists  of  the  accumulated  secretion 
of  the  night,  and  forms  at  the  meatus. 

Acute  vesical  inflammation,  causes  the  appearance  of  hexagonal  and 
caudate  pavement-cells  in  the  urine.  These  are  mixed  with  an  abundance 
of  pus-corpuscles  and  more  or  less  blood-corpuscles.  On  standing,  these 
materials  form  at  the  bottom  of  the  fluid  a  grayish-white  or  reddish-brown 
deposit.  The  reaction  of  the  urine  in  such  cases  is  acid,  unless  the  condi- 
tion is  an  acute  exacerbation  of  chronic  vesical  inflammation  or  the  result 
of  prolonged  retention  of  urine  from  some  special  cause.  Thus,  Peyer 
has  an  excellent  plate  representing  the  appearance  of  the  urine  in  a  case  of 
acute  vesical  inflammation,  with  alkaline  reaction,  occurring  in  a  lying-in 
woman  whose  bladder  had  been  paralyzed  by  the  application  of  forceps, 
as  a  consequence  of  which  catheterization  became  necessary.  Such  cases 
are  only  explicable  by  the  entrance  of  bacteria  into  the  bladder  via  a 
filthy  catheter.  This  authority  states,  however,  that,  although  acute  vesical 
catarrh  is  attended  by  acid  urine  and  usually  bacteria  are  absent,  yet  they 
may  be  present  in  spite  of  the  acidity. 

Chronic  catarrh  of  the  nech  of  the  Madder  often  occurs  without  active 
symptoms  of  infiammation.  In  such  cases  the  urine  is  acid  and  contains 
small   flakes    of   mucus   and    epithelium,   resembling,    somewhat,    urethral 


CLINICAL    FEATUEES    OF    THE    UEINE    IK"    VAEIOUS    DISEASES.  29 

threads.  The  character  of  the  epithelium  distinguishes  these  flakes  from 
the  latter,  for,  instead  of  being  round,  the  epithelium  is  of  the  pavement 
(hexagonal  and  caudate)  variety.  In  these  cases  the  nrine  is  apt  to  be  highly 
acid  if  there  is  any  obstruction  or  retention.  It  usually  occurs  in  gouty 
patients,  and  the  specific  gravity  is  apt  to  be  high.  In  addition  to  the 
flaky  material  we  have  mucus-corpuscles  and  perhaps  a  few  blood-cor- 
puscles. If  bacteria  are  introduced  from  without  by  means  of  a  dirty 
catheter  or  other  instrument,  the  reaction  of  the  urine  speedily  becomes 
alkaline,  and  we  have  definite  symptoms  of  inflammation;  in  such  cases 
we  find  more  or  less  blood,  pus,  epithelium,  and  perhaps  phosphates.  These 
materials  form  in  large  quantity  in  chronic  obstructive  disease  of  the 
genito-urinary  tract.  In  some  cases  of  chronic  vesical  inflammation  there 
are  evidences  of  a  morbid  condition  of  the  mucous  membrane  in  the  form 
of  pus,  blood,  and  epithelial  cells,  and  yet  the  urine  will  be  acid.  This  is 
explained  by  Peyer  upon  the  hypothesis  that  a  large  amount  of  acid  urine 
coming  down  from  the  kidneys  is  sufficient  to  neutralize  vesical  alkalinity, 
or,  indeed,  to  make  the  urine  acid,  if  it  be  voided  speedily  after  its  entrance 
into  the  bladder.  The  singular  feature  of  such  cases  is  the  fact  that  the 
latter  part  of  the  urine — i.e.,  the  portion  that  may  be  drawn  off  by  the 
catheter  from  behind  the  obstruction,  residual  urine — is  of  alkaline  re- 
action. The  same  phenomenon  may  occur  in  sacculation  of  the  bladder. 
Stone  in  the  bladder  and  enlarged  prostate  impart  to  the  urine  the  character- 
istics of  an  exaggerated  form  of  vesical  inflammation,  pus,  blood,  various 
forms  of  bacteria,  and  phosphates  being  present  in  abundance  and  the  urine 
strongly  alkaline. 

Pyelitis  does  not  give  rise  to  conditions  of  the  urine  that  are  pathog- 
nomonic of  their  origin,  particularly  if,  as  is  frequently  the  case,  vesical 
inflammation  co-exists,  either  as  a  secondary  or  primary  condition.  As  will 
be  seen  later  on,  inflammation  of  the  bladder  may,  by  simple  extension, 
result  in  pyelitis;  while,  on  the  other  hand,  the  irritating  products  of  in- 
flammation of  the  pelvis  of  the  kidney  may  secondarily  induce  vesical  in- 
flammation. There  is  a  form  of  pyelitis,  however,  resembling  simple 
chronic  catarrh  of  the  bladder,  occurring  frequently  in  gouty  patients,  in 
which  uneasiness  in  the  region  of  the  kidneys  in  combination  with  the 
appearance  of  more  or  less  muco-pus  and  the  characteristic  caudate  cells  of 
the  renal  pelvis  in  the  urine,  enables  us  to  diagnose  the  case  with  some 
positiveness.  In  such  cases,  however,  if  the  neck  of  the  bladder  becomes 
implicated,  the  caudate  cells  lose  their  significance. 

We  have  in  pyelitis,  pus,  blood,  and  epithelium  in  the  urine.  The 
pus  is  inclined  to  be  of  a  powdery  consistency  and  to  be  more  finely  dis- 
seminated throughout  the  nrine  than  in  chronic  vesical  infiammation.  It 
is  apt  to  be  of  a  greenish  color,  from  admixture  with  hematin.  The 
author  has  recently  seen  a  case  in  which  an  exacerbation  of  pyelitis  occurred 
in  a  young  man  who  suffered  from  stricture  and  vesical  catarrh,  during 


30  ITEINALYSIS    IX    ITS    SURGICAL    EELATIOXS. 

the  progress  of  malarial  fever.  In  this  case  the  urine  had  a  most  peculiar 
greenish  hue,  very  similar  to  what  might  have  been  expected  from  the  ad- 
mixture of  vegetable  matter.  These  special  features  of  pyelitic  urine  un- 
fortunately lose  much  of  their  significance  from  the  frequent  co-existence 
of  vesical  complications. 

Abscesses  in  the  vicinity  of ,  and  discharging  into,  the  genito-urinarij 
tract  give  rise  to  pyuria.  In  such  cases  the  profuseness  of  the  purulent 
deposit  in  the  urine  and  its  close  resemblance  to  the  pus  discharged  from 
abscesses  in  other  situations  should  lead  to  a  suspicion  of  the  condition 
present,  but  even  in  cases  in  which  the  marked  clinical  features  of  the  case 
should  serve  as  a  guide  to  a  correct  diagnosis,  the  source  of  the  pus  is 
frequently  overlooked.  Thus,  the  author  has  recently  seen  a  case  success- 
fully operated  for  abscess  secondary  to  disease  of  the  hip- joint  which  had 
discharged  into  the  bladder.  The  cause  of  the  pus  in  the  urine  in  this  case 
had  been  overlooked  by  several  competent  surgeons. 

A  case  was  recently  referred  to  the  author,  of  a  woman  who  suffered 
from  chronic  inflammation  of  the  bladder  with  discharge  of  an  immense 
quantity  of  pus  in  the  urine.  This  ease  upon  investigation  proved  to  be 
one  of  pelvic  cellulitis  with  resulting  abscess  that  had  opened  into  the 
bladder.  Suprapubic  cystotomy  with  proper  drainage  resulted  in  the  clos- 
ure of  the  vesical  opening  of  the  abscess.  The  case  passed  from  under 
observation  before  the  suprapubic  fistula  had  completely  healed.  In  one 
of  the  author's  earlier  cases  a  vaginal  cystotomy  was  successfully  performed. 
In  another  instance  the  presence  of  severe  vesical  inflammation  and  an 
abundance  of  pus  in  the  urine  following  acute  pelvic  symptoms,  demon- 
strated the  intravesical  rupture  of  a  pelvic  abscess  from  periuterine  infection. 
Fortunately  in  this  case  complete  recovery  occurred  under  antiseptic  vesical 
irrigations. 

Various  neoplastic  formations  in  the  genito-urinary  tract  cause  the  ap- 
pearance of  certain  characteristic  materials  in  the  urine.  Thus,  we  may 
have  in  various  forms  of  malignant  disease  the  appearance  of  characteristic 
cells  or  even  small  particles  of  the  growth  itself.  The  cells  of  vesical  cancer 
are  quite  large;  nucleated,  the  nucleus  being  often  multiple;  and  are  not 
unlike,  in  some  respects,  the  ciliated  cells  characteristic  of  the  mucous 
membrane  of  the  pelvis  of  the  kidney;  hence  care  should  be  taken  not  to 
confound  the  two.  In  villous  cancer  small  filamentary  particles  are  found 
in  the  urine,  these  particles  or  loops  being  covered  Avith  delicate  epithelium. 
They  may  appear  in  the  urine  spontaneously  or  at  a  variable  period  after 
the  introduction  of  instruments.  Aside  from  these  characteristic  features 
of  malignant  growths  of  the  genito-urinary  tract,  we  have  in  the  urine^ 
of  such  cases  the  characteristic  products  of  secondary  inflammation  of  the 


^  Microscopic  examination  of  the  urine  is  notoriously  unreliable,  on  the  average, 
in  vesical  neoplasms. 


CLIXICAL    FEATURES    OF    THE    TEIXE    IX    VARIOUS    DISEASES.  31 

bladder  or  pelvis  of  the  kidney,  as  the  ease  may  be,  from  irritation  or 
obstruction. 

In  hydatid  tumors  the  hooklets  of  the  echinococcus  will  be  found 
coincidently  with  the  periodic  rupture  of  the  cyst;  the  urine  containing 
these  hooklets,  being  diluted  by  the  fluid  contents  of  the  hydatid  growth, 
is  of  low  specific  gravity  and  very  pale,  unless  blood  be  present,  as  may 
be  the  case  from  rupture  of  the  sac. 

Surgical  Jcidney  imparts  certain  peculiarities  to  the  urine.  Thus,  it  is 
apt  to  be  increased  in  quantity,  with  marked  diminution  of  the  specific 
gravity.  Erichsen  records  a  case  in  which  the  patient  passed  five  pints  of 
urine  daily  of  a  specific  gravity  of  1.003.  In  such  cases  a' low  grade  of 
chronic  interstitial  nephritis  secondary  to  urinary  obstruction  with  dila- 
tion of  the  kidney  is  to  be  suspected.  The  quantity  of  albumin  in  such  a 
specimen  of  urine  is  either  very  small  or  nil.  A  few  hyaline  casts  may 
be  found,  and  possibly  no  renal  epithelium  whatever.  The  excretion  of 
urea  is  usually  sufficient  for  the  needs  of  economy,  the  relatively  low 
specific  gravity  being  compensated  for  by  the  large  quantity  of  excreted  fluid. 
It  is  to  be  remembered,  in  this  connection,  that,  as  already  stated,  the 
amount  of  urea  may  be  small,  yet  may  represent  the  total  amount  formed 
in  the  system  by  the  retrograde  metamorphosis  of  nitrogenized  material. 

In  surgical  kidney,  complicated  by  purulent  inflammation  either  of 
the  renal  pelvis  or  bladder,  there  is  apt  to  be  nothing  characteristic  shown 
by  urinalysis. 

Acute  nephritis  concerns  the  surgeon  only  as  a  possible  consequence 
of  operative  interference  with  the  genito-urinary  tract.  Upon  the  super- 
vention of  this  condition  the  urine  becomes  scanty  in  amount,  and  in  ex- 
treme cases  finally  suppressed.  Such  fluid  as  is  voided  is  of  a  dark  color^ 
smoky  in  appearance  from  admixture  with  blood,  and  of  high  specific 
gravity.  It  contains  blood-casts,  renal  epithelium,  a  relatively  large  amount 
of  albumin,  and  epithelium  from  the  renal  tubuli  in  the  form  of  casts  and 
also  free  in  the  fluid.  Caudate  epithelium  from  the  pelvis  of  the  kidney  is 
also  usually  to  be  found. 

Spermatorrhea  gives  rise  to  the  presence  of  mucoid  material  and  sper- 
matozoa in  the  urine.  In  many  cases  there  is  a  relatively  large  quantity 
of  mucus  from  hypersecretion  by  the  prostatic  follicles.  In  some  instances 
prostatic  catarrh  alone  will  give  rise  to  quite  a  quantity  of  mucus  without 
spermatozoa.  In  the  majority  of  instances  of  this  condition,  however,  more 
or  less  semen  is  present,  probably  because  of  the  patulous  condition  of 
the  mouths  of  the  ejaculatory  ducts  and  an  overdistended  condition  of  the 
vesiculce  seminales  as  a  result  of  reflex  irritation  of  the  nerves  of  sexual  sensi- 
bility produced  by  prostatic  disease. 

The  presence  of  spermatic  elements  in  the  urine  does  not  necessarily 
indicate  spermatorrhea.  Thus,  the  morning  urine  may  contain  semen  as 
a  consequence  of  prolonged  erection,  pollution,  or  intercourse  during  the 


32 


UBIKALYSIS    IX    ITS    SUEGICAL    EELATIQXS. 


night.  The  next  act  of  urination  following  prolonged  sexual  excitement 
brings  away  with  the  Yoided  urine  in  most  instances  a  large  quantity  of 
mucus  secreted  by  the  prostate^  Cowper's  glands,  and  urethral  follicles,  and 
in  some  instances  a  small  amount  of  semen. 

Peyer  states  that  he  has  found  in  certain  cases  of  sexual  excess  and 
masturbation  no  spermatozoa,  nothing  being  present  except  a  few  muciis- 
cells  and  epithelial  cells,  and  in  some  instances  a  large  number  of  beautiful, 
little,  coffin-shaped  and  pointed  crystals  of  phosphate  of  lime.  In  such 
instances  he  claims  the  urine  is  acid,  but  the  mucous  sediment  is  alkaline. 
He  states  that  he  has  been  able  to  diagnose  positively  from  this  condition 
of  the  urine  masturbation  in  young  men  who  had  at  first  jDositively  denied 


Fig.  5. — Morning  urine  in  a  spermatorrheic. 


it.  The  accuracy  of  his  deductions  from  what  seems  to  have  been  an 
accidentally  correct  diagnosis  is  questionable,  especially  as  practically  all 
youths  masturbate.  Spermatic  elements  may  be  found  in  the  urine  in 
certain  cases  of  cerebral  and  spinal  disease. 

Genito-urinary  iuberculosis  does  not  always  yield  reliable  diagnostic 
signs  in  the  urine.  In  the  case  of  renal  tuberculosis  the  urine  presents  the 
same  features  as  in  calculous  pyelitis,  which,  indeed,  may  be  a  complica- 
tion. Pus  and  epithelial  cells,  and  sometimes  small  particles  of  caseous 
material,  are  met  with.  The  bacillus  tuberculosis  is,  of  course,  pathog- 
nomonic when  found,  but  it  is  often  undiscoverable,  even  where  unequivo- 
cal tuberculosis  exists.     The  same  statement  holds  good  in  tuberculosis  of 


CLINICAL    FEATUEES    OF    THE    UKINE    IX    VAEIOUS    DISEASES.  33 

the  ureter,  bladder,  prostate,  seminal  vesicles,  testis,  and  urethra.  The 
characteristic  bacilli  in  the  urine  are  conclusive  when  detected,  but  their 
absence  in  nowise  militates  against  the  existence  of  tuberculosis.  Often 
enough,  bacilli  are  absent  from  the  urine  in  the  early  stages  of  genito- 
urinary tuberculosis,  yet  appear  in  abundance  later  on,  when  tissue- 
necrosis  occurs. 


CHAPTEE  III. 

Hematueia. 

The  presence  of  formed  or  disorganized  blood-elements  in  the  urine 
is  one  of  the  most  important  of  the  objective  evidences  of  genito-urinary 
disease.  So  important  is  it  in  its  general  relations  to  the  surgery  of  the 
genito-urinary  tract  that  it  merits  special  consideration,  more  particularly 
because  it  is  a  prominent  symptomatic  condition  common  to  a  number  of 
important  affections  of  the  genito-urinary  organs.  Although  blood  in  the 
urine  is  not  an  essential  disease,  and  is  always  symptomatic,  it  must  be 
remembered  that  we  are  sometimes  unable  to  recognize  the  precise  patho- 
logic condition  upon  which  it  depends. 

Quantity  of  Blood  Present. — The  quantity  of  blood  voided  in  different 
conditions  varies  from  an  amount  merely  sufficient  to  produce  slight  smoki- 
ness  of  the  urine  to  nearly  pure  blood. 

In  a  general  way,  the  urine  discharged  in  hematuria  dependent  upon 
morbid  constitutional  states  is  darker  in  color  than  in  cases  in  which  it  is 
due  to  disease  of  a  purely  local  character  affecting  the  mucous  membrane 
of  the  genito-urinary  tract.  It  may  also  be  stated  that,  the  nearer  the  seat 
of  hemorrhage  is  to  the  vesical  neck,  the  more  vivid  the  color  of  the  urine. 

Appearance  of  the  Urine. — The  appearance  of  the  urine  varies  con- 
siderably according  to  the  source  of  the  blood,  the  amount  present,  and 
the  length  of  time  that  has  elapsed  since  its  discharge. 

Varieties. — The  differences  in  the  characters  of  the  blood  present  in 
the  urine  have  warranted  a  division  of  cases  of  hematuria  into  (a)  hematuria 
pure  and  simple  and  (&)  hemoglohifiuria.  In  the  former  the  blood-corpuscles 
exist  intact  in  the  urine,  while  in  the  latter  they  are  not  perceptible  micro- 
scopically, the  discoloration  of  the  urine  being  due  to  disorganization  of  the 
blood-cells  and  liberation  of  their  hemoglobin,  or  blood-pigment.  Obviously 
the  pathologic  conditions  producing  hematuria  are  more  likely  to  be  of  an 
essentially  benignant  character  than  those  in  which,  as  a  result  of  profound 
hematopoietic  disturbance,  the  blood  in  the  urine  is  disorganized  when 
voided. 

Diagnosis. — The  diagnosis  of  hematuria  is  often  easily  determined 
from  the  gross  appearances  of  the  urine,  but  in  obscure  cases  the  micro- 
scope is  necessary  for  the  detection  of  the  blood-corpuscles.  In  hemo- 
globinuria the  corpuscles  being  broken  down  and  only  blood-pigment 
present,  the  spectroscope  may  be  necessary  to  determine  the  presence  of 
blood.  There  are  several  chemic  tests  that  are  both  simple  and  practical. 
A  very  popular  one  is  known  as  Day's  test.  This  consists  in  adding  a  few 
drops  of  alcoholic  solution  of  guaiac  to  the  suspected  liquid,  followed  by 
(34) 


ETIOLOGY    OF    HEMATUEIA.  35 

a  small  quantity  of  ethereal  solution  of  hydrogen  peroxid.  If  blood  be 
present  a  blue  color  results.  The  ordinary  spirit  of  turpentine,  with  the 
addition  of  a  little  tincture  of  guaiac,  also  gives  a  decided  blue  tint  to 
bloody  urine.  The  diagnosis  of  hematuria  having  been  completed,  our  in- 
vestigations have  but  just  begun,  for  it  remains  to  determine  the  source  of 
the  blood,  and  in  many  cases  this  is  a  difficult  matter. 

Etiology. — The  causes  of  hematuria  are  numerous.  The  condition 
may  be  due  to  certain  general  or  constitutional  conditions  affecting  the 
composition  of  the  blood  and  the  integrity  of  the  capillary  blood-vessels, 
as  in  scurvy  and  purpura  hemorrhagica,  the  result  in  such  cases  being 
hemoglobinuria.  It  is  most  frequently  due,  however,  to  local  disease  of 
some  portion  of  the  genito-urinary  tract  or  to  injury  of  the  mucous  mem- 
brane produced  by  the  presence  or  passage  of  urinary  calculi.  Diseases  of 
the  kidney — such  as  acute  congestion  or  inflammation,  cancer  of  the  kidney, 
rupture  of  the  kidney  from  traumatism,  pyelitis,  calculus,  reflex  renal  hy- 
peremia; acute  inflammation  of  kidney,  ureter,  and  bladder  from  poison- 
ing by  chlorate  of  potassium,  cantharides,  turpentine,  or  carbolic  acid — 
are  among  the  principal  causes  of  hematuria.  Hematuria  following  the 
paroxysmal  pain  produced  by  calculus  of  the  kidney,  ureter,  or  bladder  is 
very  common.  When  the  hemorrhage  is  due  to  renal  disease,  epithelial  or 
blood-casts  may  be  found  by  the  microscope,  these  clearing  up  the  diagnosis. 
This  means  of  diagnosis  is  greatly  facilitated  by  the  fact  that,  if  the  blood- 
cells  are  intact  when  they  enter  the  urine,  they  are  preserved  for  some  time 
and  do  not  readily  lose  either  their  shape  or  pigment.  In  scurvy,  purpura 
hemorrhagica,  malaria,  and  sometimes  in  septicemia  the  kidney  is  the  seat  of 
hemorrhage.  It  may  be,  however,  that  in  some  cases  of  these  conditions  the 
hemorrhage  originates  in  the  bladder  itself.  In  some  cases  the  entire  urinary 
tract  appears  to  be  involved. 

Among  the  general  causes  of  hematuria,  and  especially  hemoglobinuria, 
malarial  infection  holds  a  prominent  place.  This  form  is  sometimes  inter- 
mittent or  paroxysmal  in  character,  and  may  or  may  not  be  associated  with 
symptoms  of  ordinary  malarial  disease,  although  it  most  often  succeeds 
more  or  less  prolonged  malarial  infection  and  is  usually  attended  by  so 
typic  and  so  violent  malarial  symptoms  that  there  is  little  difficulty  in 
diagnosis.  Such  cases  of  hematuria  are  very  frequently  seen  in  malarious 
districts.  This  sometimes  occurs  in  a  malignant  form  that  rapidly  destroys 
life.  This  form  bears  a  strong  resemblance  to  yellow  fever.  Active  and 
passive  hyperemia  of  the  kidney  and  acute  diffuse  or  acute  hemorrhagic 
nephritis  often  cause  hematuria.  These  conditions  are  transitory:  i.e.,  the 
patient  either  dies  promptly,  or,  what  is  more  probable,  recovers.  The 
condition  may  end  in  chronic  nephritis,  in  which  event  the  hematuria 
disappears. 

There  is  a  form  of  hematuria,  prevalent  in  tropic  countries,  that 
is  produced  by  a  parasite — the  Bilharzia  hcematolia,  so  named  after  its 


36  HEilATUElA. 

discoverer,  Theodor  Bilharz — in  "«-hich  both  the  kidney  and  prostate  are 
affected  by  the  jDarasite,  both  organs  consequently  contributing  to  the  blood 
in  the  urine. 

Diseases  of  the  bladder  may  cause  hematuria,  the  conditions  giving 
rise  to  it  being  congestion,  inflammation,  vesical  calculus,  villous  tumor, 
traumatism,  and  simple  or  malignant  ulceration;  rupture  of  the  bladder, 
pathologic  or  traiimatic,  is  also  occasionally  a  cause.  Diseases  of  the  pros- 
tate, such  as  congestion,  hypertrophy,  inflammation  and  ulceration,  simple 
or  malignant,  may  also  cause  the  disease.  Passive  congestion  of  the  pros- 
tate and  bladder  may  result  from  hepatic  congestion  and  obstruction  and 
give  rise  to  blood  in  the  urine.  It  is  sometimes  the  result  of  congestion 
of  the  prostatic  plexus  associated  with  straining  efforts  at  defecation  inci- 
dental to  inflamed  hemorrhoids.  Urethral  trauma,  simple  or  specific 
urethritis,  and  organic  stricture  may  give  rise  to  urethral  hemorrhage 
which  may  or  may  not  produce  hematuria. 

Tlie  determination  of  the  source  of  urinary  hemorrhage  is  a  very  im- 
portant matter.  As  a  general  rule,  careful  exploration  of  the  urethra,  blad- 
der, and  rectum,  with  a  careful  analysis  of  the  urine  with  reference  to 
the  existence  of  renal  disease,  is  necessary  to  determine  the  source  of  the 
hemorrhage.  This  examination  of  the  urine  involves  microscopic  as  well 
as  macroscopic  and  chemic  tests.  The  origin  of  many  cases  of  hematuria 
may  be  revealed  by  thorough  study  of  the  history  and  constitutional  con- 
dition of  the  patient.  Much  may  be  learned  from  the  gross  appearance 
of  the  iirine.  When  the  hemorrhage  is  renal  the  urine  is  smoky  and  the 
blood  is  uniformly  diffused  through  it:  blood  and  epithelial  casts  are  usu- 
ally to  be  found  by  microscopic  examination.  When  the  hemorrhage  is 
vesical  or  prostatic,  the  first  urine  discharged  is  usually  clear,  the  last  few 
drops  being  bloody  and  sometimes  composed  of  nearly  pure  blood,  being 
always  wholly  or  in  part  of  a  bright,  arterial  hue.  In  prostatic  hemor- 
rhage the  first  urine  expelled  is  apt  to  contain  a  clot  or  clots  presenting 
the  general  contour  and  size  of  the  prostatic  sinus.  This  is  by  no  means 
exceptional.  Under  such  circumstances  the  blood-coagulum  is  dark  and 
quite  firm,  and  little  or  no  pure  blood  is  visible  until  the  act  of  urination 
is  nearly  completed.  "When  the  hemorrhage  is  urethral,  blood  is  likely  to 
escape  independently  of  the  act  of  urination,  and  is  always  washed  away 
with  the  first  gush  of  urine,  the  last  portion  being  clear  unless  the  hemor- 
rhage be  profuse.  In  addition  to  these  special  features,  symptoms  referable 
to  disease  of  the  particular  organ  involved  are  usually  present.  In  some 
cases  it  may  be  necessary  to  wash  out  the  bladder  with  warm  water  through 
a  catheter,  thus  removing  the  blood.  If  the  next  few  drams  of  urine  are 
bloody,  the  hemorrhage  is  probably  renal.  The  cystoscope  is  often  suc- 
cessful in  the  detection  of  the  source  of  hemorrhage  during  the  intermissiou 
of  hemorrhage.  In  some  cases  it  is  possible  to  determine  whether  one  or 
both  kidnevs  are  involved  in  the  bleedins:  bv  studvins:  the  urine  as  it  flows 


ETIOLOGY    OF    HEMATURIA.  37 

from  the  ureters  into  the  bladder  with  the  cystoscope  or  Harris's  instru- 
ment. When  all  diagnostic  means  are  inetiectual  an  exploratory  incision 
of  the  bladder  is  demanded,  and,  if  the  cause  be  discovered,  it  should  be 
removed  at  the  same  operation  if  possible. 

The  diagnostic  significance  of  blood  in  the  urine  is  succinctly  stated 
by  Ealfe  as  follows: — 

1.  Hematuria. — The  character  of  the  hemorrhage,  together  with  the  general 
and  special  symptoms,  is  usually  sufficient  to  indicate  the  part  of  the  genito-urinary 
tract  from  whence  it  is  derived.  Thus,  (a)  acute  nephritis;  smoky -to  dark-brown 
urine  persistent  for  some  days,  with  granular  and  bloody  casts  and  excess  of  albumin. 
(h)  Renal  calculus:  often  deejj  red  from  excess  of  blood,  increased  by  movement,  and 
passing  off  rapidly  if  the  patient  is  kept  quiet  in  bed;  so  that  only  a  few  blood- 
corpuscles  can  be  seen  in  the  urine.  Generally  accompanied  by  or  immediately  follow- 
ing a  severe  attack  of  colic;  retraction  of  testicle  on  side  affected,  (c)  Vesical  cal- 
culus: hemorrhage  generally  follows  undue  movement,  especially  jolting;  bladder 
symptoms  prominent;  detection  of  stone  in  bladder  by  sound,  (d)  Cancer  of  kidney: 
hematuria  very  abundant  with  large  coagula,  and  repeated  at  irregular  intervals; 
generally  tumor  in  loin,  (e)  Cancer  of  bladder:  frequent  and  profuse  hemorrhage; 
cancer-cells  in  urine  (?);  pain  referable  to  bladder,  and  a  tumor  may  be  discovered 
with  sound,  (f)  Morbid  conditions  of  the  blood:  hemorrhage  often  profuse,  but 
rarely  attended  with  formation  of  clots;  general  constitutional  symptoms  manifest, 
(g)  Intermittent  hematuria:  the  blood  passes  at  irregular  intervals,  and  is  generally 
associated  with  a  considerable  quantity  of  albumin  and  a  definite  rise  of  temperature. 
In  this  case  there  is  a  history  of  ague,  if  that  disease  has  disappeared.  It  is  some- 
times associated  with  intermittent  chyluria  or  gout. 

2.  Hematinueia  (Hemoglobinuria). — In  this  case  only  the  coloring  matter 
of  the  blood  is  present;  no  blood-corpuscles,  or  only  a  few,  are  to  be  found.  The 
attacks  come  on  in  paroxysms,  attended  with  a  chill  and  generally  pain,  with  some 
degree  of  nausea  and  slight  jaundice.  The  urine  has  a  port-wine  color,  and  is  usually 
passed  clear;  on  standing  it  deposits  a  granular  sediment  consisting  of  a  few  tube- 
casts  (fibrinous  cylinders),  epithelium,  and  crystals  of  calcium  oxalate.  In  some  cases 
crystals  of  hematin  ha^-e  been  observed. 

Certain  peculiarities  as  regards  the  time  of  appearance  of  the  hemor- 
rhage, as  regards  the  act  of  micturition,  and  certain  peculiarities  of  forma- 
tion of  the  coagula  passed  are  apt  to  lead  to  a  fairly-accurate  knowledge  of 
the  location  of  the  hemorrhage. 

In  this  connection  the  author  recalls  several  instances  of  nephritic 
calculus  in  which  small  casts  of  the  ureter,  strongly  resembling  angle- 
worms, were  passed  some  hours  after  the  onset  of  the  colic.  Where  there 
is  any  question  as  to  the  diagnosis,  the  appearance  of  such  clots  is  im- 
portant as  showing  that  the  ureter,  or  the  kidney  which  it  drains,  is  the 
site  of  the  hemorrhage-yielding  lesion. 

The  blood  may  be  detected  quite  readily  by  the  microscope  in  cases 
in  which  it  is  not  completely  disorganized.  In  the  latter  event,  however, 
the  spectroscope  may  become  necessary.  In  the  case  of  malignant  growths, 
the  assertion  that  cancer-cells  are  to  be  found  in  the  urine  is  not  justified 
by  the  facts  in  most  cases.    It  is  more  likely  to  occur — from  masses  of  the 


38  HEMATURIA. 

growth  becoming  detached — where  the  growth  is  in  the  bladder^  prostate, 
or  urethra,  than  when  the  kidney  alone  is  atfected.  In  the  latter  condition 
the  patient  dies,  worn  out  by  repeated  hemorrhages  and  cachexia,  long 
before  the  mass  could  break  down. 

Cases  of  idiopathic  hematuria  occur  in  which  the  hemorrhage  is  ap- 
jDarently  the  essential  disease  and  neither  the  source  nor  the  cause  is  dis- 
coverable; cases 'of  this  kind  are  described  by  Van  Buren  and  Keyes  and 
others.  The  author  has  seen  several  cases  where  there  apparently  existed 
no  adequate  cause  for  the  hemorrhage,  which  speedily  disappeared  with 
little  or  no  treatment  without  apparent  injury  to  the  patient.  Overheating 
and  extreme  fatigue  have  appeared  to  bear  a  causal  relation  to  some  of  the 
cases  observed.  It  seems  logical  to  attribute  such  cases  to  vasomotor  dis- 
turbance of  the  renal  circulation. 

The  condition  of  passive  congestion  of  the  prostate,  to  which  allusion 
has  already  been  made,  is  a  more  frequent  cause  of  hematuria  than  has 
been  supposed.  The  author  has  observed  several  cases  of  this  kind.  The 
following  cases  are  of  considerable  interest  in  an  illustrative  Avay: — 

Case  1. — A  young  man,  about  25  years  of  age,  was  referred  by  his  family 
physician  for  the  relief  of  urethral  hemorrhage,  which  had  occurred  almost  daily  for 
six  months.  The  doctor  liad  susi>ected  stricture,  but  as  he  had  succeeded  in  passing  a 
No.  15  English  sound,  he  concluded  that  some  disease  of  a  more  serious  character 
existed.  A  history  of  several  attacks  of  gonorrhea  was  elicited,  but  further  than  this 
nothing  had  ever  occurred  that  might  have  accounted  for  the  hemorrhage.  The 
blood  escaped  in  the  morning  with  great  regularity,  and  was  occasionally  observed  at 
other  times  during  the  day,  especially  if  violent  exercise  had  been  indulged  in.  A 
fusiform  clot  generally  escaped  with  the  first  gush  of  urine,  the  remainder  of  the  flow 
being  only  slightly  tinged  with  blood.  Constipation  had  been  a  prominent  symptom, 
and  several  internal  hemorrhoids  had  formed  before  the  hematuria  appeared.  Micturi- 
tion was  rather  frequent,  but  not  excessively  so,  as  the  patient  was  compelled  to  rise 
at  night.  Nocturnal  emissions  frequently  occurred,  and  for  several  months  there  had 
been  a  slight  gleety  discharge  from  the  urethra.  The  general  health  was  only  fair, 
digestion  being  disturbed  the  greater  part  of  the  time.  On  examination  with  the 
urethrometer,  a  stricture  of  large  caliber  was  found  in  the  penile  urethra  about  one 
and  a  half  inches  from  the  meatus,  and  a  slight  organic  contraction  could  be  detected 
at  the  bulbo-membranous  junction.  Exploration  of  these  strictures  did  not  produce 
hemorrhage.  The  prostate  was  distinctly  enlarged  and  soft,  but  not  tender  to  pressure 
or  the  passage  of  sounds.  Firm  pressure  upon  the  perineum,  however,  produced  a 
sense  of  tension  and  fullness.  As  a  preliminary  to' medical  treatment,  meatotomy  was 
performed  and  the  penile  stricture  cut  to  a  caliber  of  30  French,  the  deep  stricture 
being  treated  by  gradual  dilation.  Internal  medication  consisted  chiefly  in  remedies 
to  relieve  hepatic  congestion  in  combination  with  ergot  and  bromid  of  potassium. 
Counter-irritation  to  the  perineum  and  cold  sitz-baths  composed  the  remainder  of  the 
treatment.  Improvement  was  rapid,  the  hemorrhage  ceasing  at  the  end  of  the  first 
week  and  the  other  symptoms  disappearing  very  soon  thereafter.  The  possible  rela- 
tion of  reflex  hyperemia  of  the  prostate  incidental  to  the  penile  stricture  to  the 
hematuria  is  at  once  obvious  in  such  cases. 

Case  2. — A  gentleman,  32  years  of  age,  had  been  treated  for  slight  stricture,  the 
urethra  having  been  dilated  to  about  No.  20  French,  Avhen  he  stopped  treatment. 
Some  time  thereafter,  while   suffering  from  an  attack  of  constipation  attended  by 


EENAL    AND    IDIOPATHIC    HEMATUEIA.  39 

hemorrhoids,  he  noticed  a  small  amount  of  blood  in  the  urine.  This  recurred  daily, 
and  gradually  became  a  source  of  great  annoyance,  although  there  was  at  no  time 
any  great  loss  of  blood  nor  any  pain,  either  during  micturition  or  at  other  times. 

Upon  examination  a  stricture  of  moderately-large  caliber  was  found  at  three 
inches  from  the  meatus.  This  did  not  bleed  on  exploration.  The  prostate  was  moder- 
ately enlarged  and  there  were  slight  internal  hemorrhoids. 

The  treatment  of  this  patient  was  precisely  like  that  of  the  preceding  case,  with 
the  exception  that  the  fluid  extract  of  hamamelis,  in  small  doses,  was  substituted  for 
the  ergot.     A  cure  was  effected  in  six  weeks. 

Case  3. — This  patient,  a  healthy-looking  man  43  years  of  age,  had  never  been  ill 
until  about  three  months  previously,  and  had  never  contracted  any  venereal  disease. 
At  the  time  mentioned  he  had  strained  his  back  and  perineum  slightly  in  a  bowling 
contest,  and  shortly  thereafter  began  to  be  troubled  with  constipation,  slight  hemor- 
rhoids, and  hematuria.  The  blood  had  increased  in  quantity  until  the  urine  was  very 
largely  mixed  with  blood,  fusiform  clots  being  occasionally  observed  during  urination. 
Aside  from  the  worry  consequent  upon  the  hematuria,  the  patient  was  still  perfectly 
well;  appetite,  sleep,  and  strength  were  unimpaired;  and  there  was  no  pain.  For 
some  unaccountable  reason,  several  physicians  had  pronounced  the  case  Bright's 
disease,  and  had  treated  it  accordingly.  The  symptoms  appeared  to  warrant  a 
diagnosis  of  hemorrhage  from  the  prostate  and  vesical  neck,  this  being  determined  by 
the  absence  of  pain  and  general  symptoms,  the  shape  of  the  clots,  the  absence  of 
vesical  irritability  and  urethral  disease,  the  absence  of  tenderness  on  pressure  upon 
the  hypogastrium  and  perineum,  the  occurrence  of  hemorrhage  in  the  morning,  chiefly 
after  stool,  and  the  absence  of  blood-casts  and  other  evidences  of  renal  disease. 

Ergot,  turpentine,  and  cholagogues,  with  the  citrate  of  potassium  in  Vichy 
water,  and  a  bread-and-milk  diet  constituted  the  treatment  of  this  case,  and  was  per- 
fectly successful,  a  cure  being  affected  in  about  three  weeks. 

When  we  consider  the  intimate  association  of  the  hemorrhoidal  and 
prostatic  plexuses  in  their  relation  to  the  neck  of  the  bladder,  prostate,  and 
anus,  and  the  close  relation  of  this  venous  net-work  with  the  portal  circu- 
lation via  the  mesenteric  veins,  such  cases  are  hardly  surprising.  Con- 
sidering the  frequenc}^  with  which  a  greater  or  less  amount  of  urethral 
obstruction  is  superadded  to  simple  constipation,  thus  necessitating  more 
or  less  straining  during  micturition,  it  would,  indeed,  be  remarkable  if  such 
cases  were  not  occasionally  seen. 

Case  4.^ — Apparently  idiopathic  hematuria.  A  boy,  12  years  of  age,  was  referred 
for  marked  hematuria  that  had  appeared  at  each  act  of  micturition  for  three  or 
four  weeks.  Careful  questioning  elicited  no  history  of  injuiy  or  vesical  irritation. 
Examination  failed  to  detect  any  local  cause  for  the  hemorrhage,  the  bladder  being 
carefully  searched  for  stone.  Cystoscopy  was  unsatisfactory.  Under  restricted  diet, 
ergot,  salines,  and  rest  in  bed  the  condition  disappeared  within  a  Aveek.  The  patient 
has  been  under  observation  ever  since,  a  period  of  five  years,  and  has  had  no  recur- 
rence of  the  trouble  and  no  disturbance  referable  to  the  urinary  organs. 

There  is  a  form  of  hematuria,  of  undoubted  renal  origin,  in  which 
even  operative  exploration  of  the  particular  kidney  proved  by  the  cysto- 
scope  to  be  the  source  of  the  hemorrhage  is  productive  of  negative  results. 
In  a  case  of  the  author's  there  were  many  points  suggestive  of  renal 
calculus,  a  probable  diagnosis  of  which  was  made.    The  hematuria  had  been 


40  ■  HEMATTJEIA. 

almost  constant  for  months  and^  in  conjunction  with  the  pain,  had  pro- 
duced marked  anemia  and  emaciation. 

The  patient,  a  woman  of  30,  was  willing  to  submit  to  any  operation, 
however  tentative,  for  a  possible  chance  of  relief.  The  suspected  kidney 
on  exposure  was  found  to  be  larger  than  the  average  normal  organ  and  dis- 
tinctly congested;  but,  after  free  nephrotomy,  no  stone  nor  any  condition 
suggestive  of  malignant  or  tubercular  disease  was  found.  Cessation  of  both 
hemorrhage  and  pain  followed  the  operation.  M.  L.  Harris  has  recently 
published  eighteen  cases  of  a  similar  nature,  collected  from  the  literature, 
the  two  following  being  his  own^: — 

Case  1.— Male,  aged  51;  Ameriean;  occupation,  street-car  conductor;  of  good 
habits;  with  no  venereal  history;  had  always  been  strong  and  healthy.  In  Febru- 
ary, 1895,  without  previous  illness  or  injury,  he  began  passing  blood  in  the  urine. 
As  there  were  absolutely  no  subjective  symptoms,  he  paid  little  attention  to  it,  but 
continued  at  his  work.  After  some  three  months  he  had  gradually  become  so  weak 
from  loss  of  blood  that  he  was  unable  to  perform  his  full  day's  work,  and  it  was  for 
this  weakness  that  he  sought  advice  on  April  27,  1895.  There  were  no  symptoms 
referable  to  the  urinary  organs.  Had  he  not  observed  the  dark  color  of  the  urine  he 
would  not  have  suspected  any  urinary  trouble.  Physical  examination  failed  to  reveal 
anything  abnormal  about  any  of  the  viscera.  There  was  no  renal  tenderness,  nor  could 
either  kidney  be  felt.  An  examination  of  the  bladder,  prostate,  and  urethra  was  nega- 
tive. The  urine  was  dark  brown  in  color,  cloudy,  acid,  1018  to  1025  sp.  gr.  Small 
amount  of  albumin;  no  sugar.  The  microscope  showed  numerous  red  blood-cells,  ^^ith 
a  few  leucocytes,  no  casts,  and  no  epithelial  cells.  The  urine  was  repeatedly  exam- 
ined during  the  next  few  weeks,  but  nothing  abnormal  was  found  except  blood. 
There  was  no  elevation  of  temperature  nor  unusual  acceleration  of  pulse.  He  was  not 
a  "bleeder,"  and  had  never  had  hemorrhages  before. 

With  these  facts  before  us,  a  satisfactory  diagnosis  was  difficult  to  make.  The 
hemorrhage  was  undoubtedly  renal  in  origin.  Eenal  calculus  was  excluded  on  account 
of  the  uniform,  unchangeable  character  of  the  hematuria,  and  the  total  absence  of  pain. 

Tuberculosis  was  excluded  on  account  of  absence  of  temperature-elevation  and 
pus  in  the  urine.  Malignant  growth  seemed  most  probable,  although  no  tumor  could 
be  felt,  and  the  prolonged  uinterrupted  character  of  the  hemorrhage  was  unusual.  A 
diagnosis  was,  therefore,  withheld.  The  patient  was  placed  at  rest,  and  the  usual 
hemostatic  remedies  given.  This  line  of  treatment  was  followed  a  few  weeks,  without 
the  slightest  apparent  improvement.  This  plan  was  then  discontinued,  and,  while  con- 
sidering the  advisability  of  exploring  the  kidneys,  he  was  placed  on  general  tonics, 
with  forced  nourishment.  He  began  to  improve  at  once.  The  blood  rapidly  diminished 
in  amount,  and  by  June  5,  1895,  he  was  able  to  resume  his  occupation.  In  a  few 
days  more  the  urine  was  entirely  free  from  blood.  Some  two  and  a  half  years  have 
now  elapsed.  He  has  been  at  work  constantly  since  then,  and  a  few  days  ago  reported 
that  he  felt  perfectly  well,  and  has  had  no  recurrence  of  the  hematuria. 

Case  2. — Male,  aged  50  years;  American;  married;  occupation,  farmer.  Family 
history  negative.  Has  always  enjoyed  good  health.  He  thinks  he  had  "malarial 
fevei-"  eighteen  years  ago,  but  not  since.  He  has  never  drank  to  any  extent,  but  has 
used  tobacco  freely.  Has  never  been  subject  to  hemorrhage  of  any  kind.  No  family 
history  of  hemophilia.  Has  had  no  venereal  disease.  The  present  trouble  began  about 
three  years  ago,  when  he  noticed,  accidentally,  that  his  urine  was  quite  dark  in  color. 


^Philadelphia  Medical  Journal,  March   19,   1898. 


EENAL    HEMATUEIA    WITHOUT   LESION.  41 

At  first  this  was  not  constant,  the  urine  varying  in  color,  being  at  times  quite  clear, 
again  very  dark.  He  consulted,  a  physician,  who  found  blood  in  the  urine.  The  blood 
in  the  urine  gradually  became  more  constant,  until,  for  something  more  than  a  year 
past,  there  has  been  no  time  when  it  has  been  free  from  blood.  It  has  been  uniformly 
of  a  muddy,  dark-brown  color.  During  all  this  time  there  have  been  no  symptoms 
referable  to  the  urinary  tract;  in  fact,  nothing  to  direct  attention  to  the  urinary 
organs,  except  the  blood  in  the  urine.  Appetite  has  been  good  and  bowels  regular.  He 
had  suffered  somewhat  mentally,  fearing  some  serious  condition,  owing  to  the  per- 
sistence of  the  hematuria.  He  had  likewise  noticed,  during  the  past  few  months,  that 
he  was  becoming  perceptibly  weaker.  He  was  unable  to  do  a  full  day's  work,  and 
found  he  gave  out  much  sooner  than  formerly.  He  had  lost  8  pounds  during  the 
year,  his  present  weight  being  145  pounds.  His  mucous  membranes  were  rather  pale, 
the  pulse  regular  and  about  70  to  75;  temperature,  98.6°;  the  heart,  lungs,  and  the 
hepatic  and  splenic  areas  normal.  The  kidneys  could  not  be  felt,  nor  was  there  any 
tenderness  about  them.  In  the  rectum  Avas  found  a  small  superficial  ulcer  about 
twelve  millimeters  in  diameter.  The  urethra  was  of  normal  caliber  throughout. 
Thorough  examination  of  the  bladder  by  sounds,  irrigation,  etc.,  was  entirely  negative. 
Upon  cystoscopic  examination,  the  blood  was  easily  seen  issuing  from  the  left  ureter, 
the  urine  issuing  from  the  right  ureter  being  perfectly  clear. 

The  amount  of  urine  in  twenty-four  hours  was  32  ounces;  the  color,  very  dark 
brown  and  cloudy;  the  reaction,  acid;  sp.  gr.,  1030.  It  contained  no  sugar  and  but 
a  small  amount  of  albumin.  The  microscope  showed  very  abundant  red  blood-cells, 
few  leucocytes,  no  casts,  no  epithelial  cells.  Repeated  microscopic  examinations  were 
made  of  the  centrifuged  urine,  extending  over  a  period  of  several  days,  but  no  casts  or 
epithelial  elements  were  ever  found.    Blood-cells  were  always  abundant. 

In  considering  the  diagnosis  we  were  at  once  directed  to  the  left  kidney  as  the 
source  of  the  hemorrhage.  Renal  calculus  was  excluded  by  the  long  persistence  and 
constancy  of  the  hemorrhage,  the  fact  that  it  was  not  increased  by  exercise  or  jolting, 
nor  diminished  by  repose  and  recumbency,  and  the  total  absence  of  all  pain.  Tuber- 
culosis was  excluded  by  the  absence  of  pus  and  tubercle  bacilli  from  the  urine,  and 
the  absence  of  elevation  of  temperature  (carefully  recorded  for  several  days).  Malig- 
nancy could,  in  all  probability,  be  excluded,  owing  to  the  absence  of  a  tumor,  which 
we  would  expect  to  be  present  before  the  end  of  three  years.  We  were  thus  reduced 
to  one  of  two  conditions:  hemorrhage  from  an  angioma  of  the  pelvis  or  the  kidney — 
which  was  not  likely,  owing  to  the  uniformity  and  constancy  of  the  hemorrhage— or 
so-called  angioneurotic  hematuria  or  renal  hemorrhage  without  known  pathologic 
change — the  most  probable  diagnosis. 

Medicinal  treatment  being  ineffectual,  it  was  decided  to  explore  the  kidney.  The 
left  kidney  was  therefore  cut  down  and  found  to  be  normal  in  location,  size,  external 
appearance,  and  consistency.  It  Avas  then  slit  open  freely  along  the  convex  border, 
opening  widely  the  pelvis.  The  fibrous  capsule  was  easily  detachable ;  the  cut  surface, 
as  well  as  the  pelvis,  so  far  as  could  be  determined  by  sight  and  touch,  were  normal. 
In  fact,  the  most  careful  examination  within  and  without  failed  to  discover  the 
slightest  abnormality  about  the  kidney.  It  is  much  to  be  regretted  that  a  portion  was 
not  excised  for  microscopic  examination.  The  incision  in  the  kidney  was  sutured  with 
catgut,  and  the  wound  closed.  On  the  first  day  after  the  operation  the  urine  was  still 
bloody;  on  the  second,  much  clearer;  on  the  third,  quite  bloody  again;  thereafter  it 
became  rapidly  clearer,  and  by  the  end  of  the  first  week  no  more  blood  could  be  found 
with  the  microscope.  Recovery  Avas  without  incident.  The  man  left  the  hospital  nine- 
teen days  after  the  operation.  Not  a  trace  of  albumin  or  blood  could  be  found  in  the 
urine.  The  patient  Avas  much  relieved,  mentally,  by  the  cessation  of  his  trouble.  He 
Avas  last  heard  from  six  months  after  the  operation,  in  first-class  condition,  Avithout 
recurrence  of  hematuria. 


42  HEilATUEIA. 

Harris  remarks  upon  liis  cases  as  follows: — 

These  two  cases  are  of  particular  interest  owing  to  their  negative  points,  there 
being  absolutely  no  svmptoms  except  the  hematuria,  with  its  resultant  anemia  and 
general  weakness.  That  there  was  no  marked  or  serious  lesion  of  the  kidneys  is  evi- 
dent from  the  fact  that  both  patients  permanently  recovered.  When  Klemperer  read 
his  article  "Ueber  Xierenblutungen  bei  gesunden  Xieren"'  (Deutsche  mediciirische 
WocJienschrift,  X05.  9  and  10,  1897)  before  the  Society  of  Internal  Medicine  in  Berlin, 
in  December,  1896,  he  was  criticised  by  some  for  the  use  of  the  term  "healthy  kidneys." 
It  was  considered  that  a  kidney  permitting  the  constant  escape  of  blood  from  it  must 
be  looked  upon  as  pathologic.  In  defense  of  this  point  Klemperer  cited  numerous 
instances  of  vicarious  menstruation  and  of  hemorrhage  from  different  organs  of 
"bleeders"  in  whom  no  pathologic  condition  of  the  bleeding  organs  could  be  deter- 
mined; but  more  important  still,  as  bearing  directly  upon  the  subject,  he  presented 
reports  of  cases  wherein  the  most  careful  macroscopic  and  microscopic  examination 
by  competent  observers  of  kidneys  removed  for  uncontrollable  hemorrhage  had  failed 
to  detect  the  slight-est  pathologic  change.  Others  have  met  with  similar  eases,  and, 
acting  upon  the  suggestions  of  Klemperer,  Elb  collected  all  the  cases  he  could  find  in 
the  literature  up  to  1896,  and  published  them  in  his  dissertation.  These  cases  were 
eight  in  number. 

Harris  succeeded  in  collecting  the  histories  of  eighteen  cases,  includ- 
ing his  own.  His  comments  upon  them  constitute  a  most  yaluahle  addition 
to  the  literature  of  hematuria,  and  are  herewith  presented  in  full: — 

We  have  here  18  cases,  including  my  own,  or,  if  we  exclude  one  which  was 
probably  tuberculous,  in  which  there  was  found  a  small  contracted,  dense,  tough 
kidney,  we  have  16  cases  of  persistent,  severe  renal  hematuria.  Avithout  perceptible 
lesions  of  the  kidneys. 

As  to  sex,  there  are  7  males  and  9  females.  The  ages  range  from  19  to  54.  In 
all  cases  the  hematuria  began  without  known  cause  in  individuals  in  apparent  health, 
and  was  usually  discovered  accidentally,  no  symptoms  haA'ing  directed  attention  to  the 
urinary  organs.  The  urine  contained  no  abnormal  constituents,  except  the  red  and 
white  blood-cells  and  albumin  corresponding  to  the  amount  of  blood  present. 

It  will  thus  be  seen  that  the  diagnosis  must  at  present  rest  mostly  upon  negative 
findings,  or  diagnosis  by  exclusion.  We  miss  the  casts  and  renal  epithelium  of  nephritis 
in  the  urine;  the  tubercle  bacilli,  other  micro-organisms,  pus,  crystals,  sand,  or  gravel 
of  infective  inflammations,  calculi,  etc.;  there  were  no  enlargements  of  the  kidney 
or  unusual  groups  of  cells  in  the  lu-ine  as  in  malignant  tumors,  no  constitutional 
symptoms  of  uremic  or  septic  intoxication — in  fact,  as  stated,  the  findings  were  nega- 
tive, with  the  exception  of  the  hematuria  and  its  resulting  anemia. 

Concerning  the  etiology  and  pathology  of  the  condition,  little  that  is  definite 
can  be  said.  Could  an  accurate  analysis  be  made  of  the  cases  here  reported,  it  is 
quite  jjrobable  that  not  all  of  them  would  be  found  due  to  the  same  cause ;  still  there 
is  sufficient  similarity  in  the  cases  to  warrant  placing  them  in  a  class  by  themselves 
until  more  definite  knowledge  may  possibly  lead  to  further  classification. 

I  cannot  agree  with  Klemperer  in  considering  these  kidneys  as  healthy.  A  kidney 
that  permits  the  escape  of  blood  for  weeks  or  months,  or  even  years,  cannot  be  looked 
upon  as  normal,  notwithstanding  the  fact  that  no  definite  lesions  have  so  far  been 
discovered. 

To  bridge  over  this  lack  of  knowledge  the  influence  of  the  nervous  system  has 
been  called  in  to  explain  these  cases.  It  is  thus  sought  to  explain  the  sudden  appear- 
ance of  the  hematuria  following  excitement,  or  the  equally  sudden  cessation  of  the 


EEXAL    HEMATUEIA    WITHOUT    LESION.  43 

bleeding  folloAving  different  acts  supposed  to  produce  some  impression  upon  the  nervous 
centers.  Klemperer  uses  the  term  "angione.urotic  hematuria"  in  these  cases.  Without 
denying  the  possibility  of  the  nervous  system's  influencing  these  cases,  it  appears  to 
me  that  there  is  one  fact  which  strongly  militates  against  the  acceptance  of  the 
neurotic  theoi-y  as  the  main  element,  namely:  in  all  of  the  cases  where  the  fact  was 
determined,  16  of  the  18  cases  (in  2  cases  not  determined),  but  one  kidney  was  affected. 
This,  to  my  mind,  must  indicate  some  local  condition.  Any  influence  from  nerve- 
centers  upon  organs  so  mutually  and  reciprocally  related  as  are  the  kidneys  would 
most  certainly  affect  both  organs,  unless  there  existed  some  local  determining  con- 
ditions. 

The  fact  that  simple  nephrotomy  has  almost  uniformly  been  followed  by  im- 
mediate cessation  of  the  bleeding,  is  no  proof  against  local  disease.  In  a  ease  in  which 
very  small,  contracted,  hard,  dense  kidney  was  foimd,  complete  recovery  followed 
simple  nephrotomy,  and  continued  until  the  patient's  death,  some  seven  or  eight  years 
later.  In  one  case  of  renal  tuberculosis,  with  severe  hematuria,  simple  nephrotomy 
was  followed  by  cessation  of  the  bleeding  for  18  months.  Harrison  has  shown  that  in 
some  eases  of  acute  nephritis,  with  marked  albuminuria  and  scanty  secretion,  the 
urine  has  lost  its  albumin  and  regained  its  normal  flow  almost  immediately  after 
simple  nephrotomy  or  acupuncture.  In  these  cases  it  must  be  acknowledged  that 
definite  pathologic  conditions  were  at  least  symptomatically  cui*ed  by  simple  nephrot- 
omy. In  all  of  the  18  cases  here  recorded  simple  nephrotomy  was  done.  Of  these, 
1  died.  Of  the  10  recoveries,  9  Avere  completely  relieved  of  the  hematutda.  In  1,  in 
which  the  kidney  was  exposed,  but  not  cut  into,  no  benefit  followed.  In  5  cases 
nephrectomy  was  done ;  1  of  these  died.  It  was  the  case  which  had  not  been  benefited 
by  the  exposure  of  the  kidney  some  two  years  before.  The  4  recoveries  Avere  all 
permanently  relieved.  Of  the  remaining  3  cases,  1  recovered  under  tonics  and  nourish- 
ment, 1  under  cold  baths,  and  1  following  cystotomy  for  the  purpose  of  catheterizing 
the  iireters. 

In  closing,  while  the  number  of  cases  is  too  small  to  warrant  any  definite  con- 
clusions, I  think  the  following  statements  are  justified:  — 

1.  There  is  a  condition  of  renal  hematuria  not  due  to  the  usually-accepted  causes, 
namely:  acute  nephritis,  calciili,  tuberculosis,  septic  infection,  malignant  and  non- 
malignant  new  formations,  hemophilia,  injuries,  malaria,  intoxications,  etc. 

2.  There  is  probably  in  these  cases  a  local  lesion  in  the  kidney  which  may  be 
strongly  influenced  by  the  nervous  system. 

3.  With  our  present  knowledge  we  are  unable  to  state  what  the  pathologic 
changes  are. 

4.  These  cases  have  not  been  benefited  by  the  usual  hemostatic  remedies. 

0.  After  a  reasonable  trial  of  other  methods  of  treatment,  including  tonics,  cold 
baths,  etc.,  if  unsuccessful,  simple  nephrotomy  should  be  performed. 

6.  Owing  to  the  almost  uniform  success  of  simple  nephrotomy,  primary  nephrec- 
tomy should  never  be  performed. 

The  author  is  inclined  to  the  vasomotor  theory  of  the  origin  of  the 
interesting  class  of  cases  jnst  described,  the  more  especially  as  such  an 
explanation  best  harmonizes  with  the  condition  found  in  the  single  case 
in  which  he  has  had  the  opportunity  of  inspecting  the  kidney.  As 
Harris  says,  the  nervous  correlation  of  the  two  kidneys  is  most  intimate; 
but  it  does  not  therefore  follow  that  both  organs  are  necessarily  involved 
simultaneously  in  vasomotor  perturbations;  if  so,  this  physio-pathologic 
phenomenon  is  peculiar  to  the  kidney  alone  of  all  the  tissues  and  organs 


44  HEMATUEIA. 

of  the  body.  It  is  possible  that  irritation  produced  by  a  crystallizing  out 
of  the  solid  matters  of  the  urine,  short  of  an  amount  necessary  to  form 
a  distinct  calculus,  may  be  localized  in  a  single  kidney,  causing  hematuria. 
This  is  consistent  with  the  known  clinical  fact  that  definite  calculi  are 
often  limited  to  a  single  kidney.  It  is  by  no  means  impossible  that  sup- 
posedly idiopathic  renal  hematuria  is  sometimes  a  concomitant  of  what  may 
be  termed  the  precalculous  stage  of  renal  lithiasis.  Another  possibility  is 
that  the  hemorrhage  is  significant  of  the  precancerous  stage  of  malignant 
disease. 

The  author  desires  to  call  special  attention  to  a  class  of  cases  in  which 
hematuria  of  prostatic  origin  is  the  first  symptom  of  prostato-vesical  tuber- 
culosis. In  one  ease  of  this  kind,  at  present  under  his  care,  the  hema- 
turia disappeared  under  treatment,  but  vesical  symptoms  developed  after 
a  time,  and  the  tell-tale  bacilli  were  found  in  large  numbers  in  the  urine. 

TeeatmejSTT. — The  treatment  of  hematuria  necessarily  involves  the 
proper  management  of  its  causal  conditions  when  they  are  discoverable. 
Morbid  constitutional  conditions  require  correction,  but  it  would  be  hardly 
proper,  in  this  connection,  to  dwell  upon  the  treatment  of  purpiu-a  hemor- 
rhagica and  scurvy,  as  they  properly  belong  to  another  department  of  medi- 
cine. It  is  also  unnecessary  to  give  the  minutice  of  treatment  of  the  various 
local  causes  of  hematuria,  inasmuch  as  it  would  only  be  a  duplication  of 
what  will  be  said  in  the  special  discussion  of  these  diseases.  In  a  general 
way,  inflammation  of  the  kidneys,  prostate,  or  bladder  requires  hot  baths, 
the  application  of  leeches  and  hot  fomentations,  and  the  administration  of 
saline  cathartics  and  alkaline  diuretics.  Gallic  acid,  matico,  ergot,  or  tur- 
pentine, in  combination  with  any  of  the  various  demulcents  that  will  be 
mentioned  later  on,  are  indicated  in  cases  where  hemorrhage  is  alarming 
In  inflammatory  conditions  hemorrhage,  as  a  rule,  should  not  be  checked. 
The  author  especially  desires  to  extol  turpentine  in  the  internal  treatment  of 
hematuria.  It  may  be  given  in  emulsion;  10  minims  to  the  dram,  and 
repeated  every  three  hours,  with  due  regard  to  possible  strangury.  If 
passive  congestion  or  hyperemia  of  any  portion  of  the  genito-urinary  tract 
exists,  the  portal  sj^stem  requires  relief  by  mercurial  cathartics,  and  the  local 
blood-supply  must  be  regulated  by  the  administration  of  ergot  and  hama- 
melis.  The  diet  should  be  restricted  as  nearly  as  possible  to  the  regimen 
alluded  to  in  the  chapter  on  genito-urinary  hygiene.  As  a  rule,  catheter- 
ism  should  be  avoided,  especially  if  the  urethra,  prostate,  or  vesical  neck 
be  the  source  of  the  hemorrhage.  Sometimes,  however,  the  bladder  becomes 
so  completely  filled  with  coagula  as  to  present  a  strong  resemblance  to  the 
gravid  uterus.  In  such  cases  the  fluid  portion  of  the  blood  and  urine 
should  be  drawn  off  and  the  coagula  washed  away  with  a  double-current 
catheter,  .a  mild  alkaline  solution  being  best  for  this  purpose.  A  digestive 
solution  of  pepsin  and  hydrochloric  acid  has  been  recommended  for  the 
purpose  of  dissolving  vesical  clots,  and  has  been  claimed  to  be  very  effica- 


TKEATMEXT  OF  HEMATUEIA.  45 

cious.  It  may  be  necessary,  after  removal  of  the  clots,  to  attempt  local 
hemostasis  by  means  of  hot  water  or  astringent  irrigations.  Antipyrin  in 
10-per-cent.  solution  is  very  valuable  for  this  purpose.  In  no  case  should 
undue  haste  be  exhibited  in  the  attempt  to  evacuate  clots,  as  it  is  desirable, 
where  possible,  to  wait  until  the  hemorrhage  has  subsided.  If  decomposi- 
tion of  the  clot  occurs,  antiseptic  irrigation  is  necessary.  In  such  cases, 
also,  the  administration  of  eucalyptus,  boric  acid,  salicylic  acid,  creasote, 
salol,  or  guaiacol  may  assist  in  maintaining  an  aseptic  condition  of  the 
contents  of  the  bladder.  Great  care  should  always  be  taken  to  maintain 
asepsis  in  vesical  manipulations  in  hematuria.  Superadded  infection  is  a 
very  serious  matter.  The  litholapaxy  evacuating-tube  is  often  serviceable 
in  removing  clots. 

Cases  of  vesical  hematuria  occasionally  occur  in  which  hemorrhage  is 
so  severe  and  uncontrollable  that  suprapubic  cystotomy  and  packing  the 
bladder  with  iodoform  gauze  are  demanded.  Drainage-tubes  may  be  used, 
although  not  usually  necessary.  They  should  be  passed  down  to  the 
vicinity  of  the  ureteral  orifices,  the  gauze  being  packed  around  them. 

The  indications  for  the  treatment  of  cases  of  hematuria  dependent 
upon  passive  congestion  of  the  prostate  and  vesical  neck  are  quite  simple, 
as  may  be  seen  by  the  cases  of  that  condition  that  have  been  described. 
They  consist  chiefly  in  the  relief  of  venous  obstruction  by  laxatives,  espe- 
cially such  as  act  upon  the  liver,  and  the  removal  of  urethral  contractures 
by  operation  or  dilation.  Eemedies,  such  as  ergot  and  hamamelis,  which 
act  upon  non-striated  muscular  fiber  are  quite  essential,  but  of  secondary 
importance.  The  sexual  function  always  requires  a  certain  amount  of  con- 
sideration, and  the  diet  should  be  restricted  to  as  unstimulating  a  regimen 
as  possible.  Neutralization  of  the  urine  should,  of  course,  be  accomplished 
as  a  matter  of  routine.  With  respect  to  the  sexual  function,  the  author  has 
experienced  one  fatal  case  of  hematuria  coming  on  ten  days  after  a  perineal 
urethrotomy,  in  which  sexual  excitement  and  resultant  hyperemia  had  much 
to  do  with  the  unfortunate  result.  Such  cases  emphasize  the  necessity  of 
sexual  continence,  psychic  as  well  as  physical,  in  all  conditions  of  the  lower 
portion  of  the  sexual  tract  characterized  by  hematuria. 


CHAPTER  IV. 

The  Bacteeiologic  Eelatioxs  of  Gexito-  Ueixaey  Ixfections  and 
Secoxdaet  Ixfectioxs  axd  Toxemias  of  Ueixaey  Oeigix. 

MoDEEN  bacteriologic  research  has  shed  much  light  upon  many  ohscnre 
points  in  genito-urinary  pathology.  Many  of  the  phenomena  of  disease 
affecting  the  urinary  tract,  or  secondary  to  such  local  disease,  have  been 
solved  within  recent  years  by  the  discovery  of  the  relation  of  pathogenic 
organisms  to  them,  and  no  text-book  upon  genito-urinary  diseases  can  be 
considered  comprehensive  without  a  general  resume  of  the  most  important 
facts  in  genito-urinary  germ-pathology.  In  presenting  these  more  recent 
developments  in  the  study  of  genito-urinary  disease,  the  author  does  not 
desire  to  be  understood  as  claiming  that  recent  discoveries  of  the  important 
relation  of  pathogenic  organisms  to  both  primary  and  secondary  pathologic 
conditions  of  the  genito-urinary  tract  justify  sweeping  away,  as  if  they 
were  so  much  rubbish,  the  clinical  observations  and  pathologic  deductions 
of  past  generations  of  surgeons.  Their  observant  eyes,  well-trained  fingers, 
and  logical  minds  were  often  productive  of  material  so  valuable  that  we 
can  only  regret  that  their  methods  of  study  and  observation  were  not  sup- 
plemented by  the  microscope. 

Urinary  toxemia  is  unquestionably  the  most  important  of  all  etiologic 
factors  in  its  relations  to  the  general  accidents  of  genito-urinary  pathology 
and  practice.  The  composition  of  the  normal  urine  per  se  and  the  absorp- 
tion of  that  fluid  have  nothing  to  do  with  the  resulting  pathologic  proc- 
esses, which  are  invariably  due  to  an  alteration  of  the  composition  of  the 
urine  through  the  medium  of  micro-organisms  of  various  kinds.  The  pre- 
cise character  of  these  micro-organisms  has  by  no  means  been  definitely 
settled.  That  the  ordinary  bacteria  of  decomposition  have  much  to  do  with 
urinary  toxemia  is  probable,  and  some  modern  researches  tend  to  show  the 
existence  of  a  special  type  of  micro-organism  in  decomposing  urine. 

The  particular  product  of  urinary  decomposition  that  possesses  general 
pathogenic  properties  has  elicited  much  discussion.  That  the  ammonia 
developed  in  decomposing  urine  produces  general  toxemia  is  no  longer 
believed;  that  it  may  produce  local  pathologic  changes  within  certain  limits 
is  admitted,  but  only  in  so  far  as  it  acts  as  an  irritant  of  greater  or  less 
intensity.  It  cannot  be  positively  stated  that  any  particular  chemic  com- 
pound is  the  cause  of  the  toxemic  conditions  resulting  from  genito-urinary 
disease,  injury,  or  operation,  although  we  are  warranted  in  assuming  that 
such  compounds  are  the  principal  etiologic  factors  in  such  conditions. 
Eeasoning  by  analogy,  we  are,  perhaps,  safe  in  the  inference  that  they  are 
toxins  similar  to,  if  not  identic  with,   the   ptomains  and  leucomains   of 

(46) 


SEPTIC    ABSOEPTION.  47 

which  we  now  hear  so  much.  The  function,  then,  of  microbial  organisms 
in  toxemias  of  g^enito-urinary  origin  woukl  seem  to  be,  in  general,  of  an 
indirect  character,  it  being  the  product  of  the  micro-organisms,  and  not  the 
germs,  'per  se,  that  produces  the  difficulty.  There  are,  of  course,  cases  of 
infection  that  are  unquestionably  due  to  special  types  of  micro-organisms — 
ordinary  septic  microbes  playing  an  important  role. 

In  considering  the  relation  of  septic  absorption  to  the  general  febrile 
accidents  of  genito-urinary  practice  it  must  be  remembered  that  the  ab- 
sorptive power  of  the  intact  vesical  mucosa  is  very  slight,  while,  as  experi- 
ments have  shown,  that  of  the  normal  urethral  mucous  membrane  is  very 
great.  Absorption  of  toxic  materials  by  the  unbroken  urethral  mucous  mem- 
brane readily  occurs.^  Earely,  if  ever,  does  the  intact  epithelium  of  the 
vesical  mucosa  absorb  toxic  or  other  materials,  even  when  they  have  re- 
mained in  the  interior  of  the  bladder  for  a  prolonged  period. 

It  is  probable  that  absorption  by  the  lymphatics  bears  a  very  important 
relation  to  the  septic  infection  that  sometimes  results  from  genito-urinary 
operations.  A  striking  analogy  is  found  in  the  metro-lymphangitis  that  so 
often  constitutes  a  starting-point  for  general  septic  infection  in  the  puer- 
perium.  Personally  the  author  is  inclined  to  attribute  relatively  greater 
importance  to  absorption  by  the  venous  channels  than  to  that  by  the  lym- 
phatics in  some  cases  of  general  infection  from  the  genito-urinary  organs; 
still,  it  must  be  acknowledged  that  the  septic  infection  may  take  its  point 
of  departure  in  a  septic  lymphangitis.  Other  things  being  equal,  it  would 
be  natural  to  expect  absorption  by  the  veins  to  result  in  general  septic 
infection  more  quickly  than  in  the  case  of  absorption  by  the  lymphatics. 
A  point  that  it  is  well  to  bear  in  mind  is  the  fact  that  absorption  by  means 
of  the  veins  is,  perhaps,  not  necessarily  followed  by  a  thrombophlebitis. 
Eapid  general  septic  intoxication  with  a  fatal  result  may  possibly  occur 
before  thrombophlebitis  has  time  to  develop. 

Eegarding  the  presence  of  a  specific  type  of  micro-organism  as  a  cause 
of  urinary  infection,  a  number  of  varieties  of  microbes  have  been  observed 
by  various  investigators  in  pathologic  urine  and  in  surgical  lesions  of  the 
kidneys.  It  is  not  surprising  that  the  immortal  pioneer  in  bacteriology, 
Pasteur,  should  have  suspected  the  truth  regarding  urinary  infection  nearly 
twenty-five  years  ago.  As  early  as  1875  he  publicly  expressed  the  opinion 
that  pathogenic  microbes  accidentally  introduced  into  the  bladder  were  the 
cause  of  urinary  infection.  During  a  discussion  by  the  Parisian  Academy, 
he  said: — 

If  I  had  the  honor  to  be  a  surgeon  I  would  never  introduce  an  instrument 
into  a  patient's  bladder  without  having  observed  the  most  rigid  precautions  to  avoid 
the  introduction  of  germs  from  the  external  atmosphere. 


'  Certain  accidents  with  cocain  used  as  a  urethral  anesthetic  show  this  rather 
too  emphatically. 


48  EELATIOX    OF    BACTEEIOLOGY    TO    GEXITO-rEIXAKT    DISEASE. 

All  the  various  conditions  embraced  under  the  term  surgical  kidney 
— save  the  results  of  backward  pressure  pure  and  simple — are  unquestion- 
ably the  result  of  infection  from  the  more  external  portions  of  the  genito- 
urinary tract.  Ascending  nephritis  has  been  shown  by  Klebs,  Virchow, 
and  others  to  be  due  to  parasitic  infection.  The  microbes,  after  entering 
the  bladder,  ascend  along  the  ureters,  infect  the  pelves  of  the  kidneys, 
and  even  penetrate  into  the  secreting  structure  itself.  According  to  Lan- 
cereaux,  renal  abscesses  under  such  circumstances  contain  the  same  microbes 
that  are  found  in  pathologic  urine.  Microbes  have  been  found  by  many 
investigators  in  pyelonephritis,  these  organisms  being  in  some  instances 
bacteria  and  in  others  micrococci.  The  streptococcus  pyogenes  has  been 
found  in  conjunction  with  various  other  forms  of  microbes,  both  bacteria 
and  micrococci,  the  staphylococcus  pyogenes  being  especially  frequent. 

A  point  of  interest  regarding  the  relation  of  bacterial  infection  to 
genito-urinary  disease  is  the  occurrence  of  descending  infection  of  the  kid- 
ney, ureter,  and  bladder.  It  has  been  shown  that  pathogenic  germs  may 
attack  primarily  the  glandular  structure  of  the  kidney,  and  that  subse- 
quently either  these  germs  or  their  ^jroducts  produce  infection  of  the  more 
external  portions  of  the  genito-urinary  tract:  e.g.,  a  cystitis  may  result 
from  a  primary  septic  nephritis  acquired  by  infection  through  the  medium 
of  the  general  circulation.  It  has  been  demonstrated  that  certain  circulatory 
disturbances  of  the  genito-urinary  tract  afford  an  invitation  for  germ- 
infection.  Thus,  Heubner  ligated  temporarily  the  vesical  arteries;  he 
then  released  the  vessels  and  observed  that  the  influx  of  blood  was  fol- 
lowed by  coagulation-necrosis  and  thickening  of  the  bladder-walls.  He 
then  found  that  if  coincidently  with  the  removal  of  the  constriction  of 
the  circulation  he  injected  pathogenic  organisms  into  the  blood,  septic 
cystitis  and  gangrene  of  the  vesical  mucosa  resulted.  Guyon  performed 
similar  experiments  upon  the  kidneys  with  a  similar  result,  as  regards  both 
the  effect  of  the  circulatory  disturbance  and  the  locus  minoris  resistentioe 
afforded  pathogenic  organisms  subsequently  entering  the  kidney  by  means 
of  the  general  circulation. 

In  1886  Bumm  reported  eight  cases  of  puerperal  cystitis  in  which  he 
found  a  micrococcus  common  to  all  that,  according  to  Halle,  was  probably 
the  staphylococcus  aureus.  Clado,  in  1887,  isolated  from  pathologic  urine 
a  bacillus  that  he  described  as  a  septic  form  of  bacterium  of  the  bladder. 
He  experimented  upon  animals  with  this  bacillus  and  produced,  by  its  in- 
troduction into  the  bladder,  cystitis.  Injection  of  the  same  micro-organism 
into  the  peritoneum  resulted  in  the  death  of  the  animal.  In  three  cases  of 
urinary  fever  this  author  found  in  two  living  patients  the  same  bacillus  in 
blood  drawn  from  the  liver,  and  in  one  autopsy  he  found  the  same  organism 
in  the  blood.  Other  experimenters  have  isolated  from  pathologic  urine 
micro-organisms  which,  injected  into  animals,  produce  nephritis.  Halle, 
who  has  written  what  is  possibly  the  most  comprehensive  article  upon 


MICKOBES    IN    UEINE.  49 

urinary  infection,  has  made  some  very  interesting  observations.  In  1887 
this  author  published  the  very  interesting  case  upon  which  he  first  formu- 
lated his  theory  of  urinary  infection.^  The  patient  was  affected  by  imper- 
meable stricture  with  intense  cystitis,  and  presented,  after  each  attempt 
at  forcible  catheterism,  violent  febrile  complications  that  finally  resulted 
in  death.  The  purulent  urine  collected  and  cultivated  during  life  fur- 
nished a  pure  culture  of  a  known  liquefying  bacterium.  At  the  autopsy 
this  same  bacterium  was  found  in  a  condition  of  purity  in  the  urine  of 
the  renal  pelvis,  the  parenchyma  of  the  kidney,  and  in  miliary  abscesses  in 
the  renal  structure.  It  was  also  found  in  the  general  blood-circulation 
and  in  the  liver.  This  bacterium  injected  into  the  peritoneum  of  a  monkey 
caused  speedy  death  by  general  infection.  The  bacterium  in  this  case 
was  subsequently  recognized  as  identical  with  the  germ  isolated  from  urine 
by  Clado.  In  1888  Albarran  and  Halle  published  an  elaborate  bacteriologic 
study  of  a  case  of  urinary  infection  observed  in  the  Hopital  Necker,  with 
numerous  experiments  upon  animals.^  These  authors  observed  this  bac- 
terium in  47  out  of  50  examinations  of  pathologic  urine.  In  35  urines, 
studied  by  culture,  15  contained  this  bacterium  in  a  condition  of  purity; 
in  20  other  cases  it  was  associated  with  other  micro-organisms.  In  19 
autopsies,  made  immediately  after  death,  the  pelvis  of  the  kidney  contained 
this  bacterium  in  18  cases.  It  was  also  found  unassociated  with  other 
bacteria  in  the  pus  of  a  case  of  pyonephrosis  removed  by  incision.  It  was 
found  in  3  cases  of  periurethral  urinary  abscess  and  in  14  cases  of  infectious 
nephritis.  In  2  cases  of  acute  febrile  infection  an  early  autopsy  showed 
this  organism  in  the  blood,  the  liver,  and  the  spleen  in  a  condition  of  purity. 
In  6  cases  of  fatal  urinary  fever  of  slow  development  culture  of  the  blood 
in  the  large  vessels,  made  immediately  after  death,  in  4  cases  yielded  this 
bacterium  in  a  condition  of  purity.  With  this  organism  the  authors  pro- 
duced (1)  cystitis  in  animals  by  injecting  it  into  the  bladder  after  ligature 
of  the  veins,  (2)  fatal  general  infection  by  inoculation  in  the  serous  cavities, 
(3)  localized  suppuration  by  inoculation  of  the  cellular  tissue,  and  (4)  sup- 
purative pyelonephritis  with  renal  abscess  by  injection  into  the  ureter  after 
ligature.  It  would  be  a  work  of  supererogation  to  present  all  of  the  con- 
clusive experiments  made  by  the  foregoing  experimenters. 

It  is  interesting  to  note  the  marked  pyogenic  properties  of  the  microbe 
discovered  by  Albarran  and  Halle. 

Krogius^  discovered  a  peculiar  microbe  in  purulent  ammoniacal  urine. 
In  ten  specimens  of  urine  this  author  isolated  in  three  instances  a  micro- 
organism quite  different  from  that  described  by  Albarran  and  Halle,  both 


^  Halle:    Bulletin  de  la  Societe  Anatomique,  October,  1887. 

-Albarran    et   Halle:     "Xote   siir   une   Bacterie   pyogene   et   sur   son   rule   dans 
I'infection  urinaire."    Academy  of  Medicine.  August  21,  1888. 
^Krcigius:     Society  de  Biologie.  Julv  23.  1890. 


50  EELATIOX    OF    BACTERIOLOGY    TO    GEXITO-rEINAEY    DISEASE. 

in  the  method  of  its  formation,  its  size,  and  its  coloring  properties.  The 
inoculation  of  this  bacillus  in  the  cellular  tissue,  veins,  and  peritoneum  of 
the  rabbit  killed  the  animal  verj^  speedily  in  some  instances;  in  others  at 
a  later  period.  At  the  point  of  inoculation  the  bacillus  produced  edema 
and  gangrene  of  the  cellular  tissue,  but  no  suppuration.  Sterilized  cultures 
were  not  so  active.  This  bacillus  Krogius  termed  the  urohaciUus  lique- 
faciens  septicus.  The  researches  of  this  author  have  been  supported  and 
confirmed  by  others  since  his  original  discovery. 

As  illustrative  of  the  many  types  of  germs  that  have  been  found  in 
pathologic  urine  taken  from  twenty-nine  cases  of  cystitis,  Eovsing's  studies 
were  very  interesting.  These  comprised  twelve  species  of  microbes,  includ- 
ing some  varieties  with  which  we  are  already  familiar,  such  as  the  hacillus 
tuberculosis;  staphylococcus  albus,  citreus,  and  aureus;  and  new  varieties 
to  which  he  applied  the  names  of  streptococcus  urece  pyogenes,  coccohacillus, 
urece  pyogenes,  diplococcus  urece  pyogenes,  micrococcus  urece  pyogenes  flavus, 
and  four  other  varieties,  which,  as  Halle  remarks,  are  nothing  but  the  four 
preceding  forms  deprived  of  their  properties  of  pathogenesis.  Experi- 
ments upon  animals  showed  the  pathogenic  properties  of  these  various 
microbes. 

The  point  of  greatest  interest  is  the  fact  that  recent  investigations 
have  shown  many  of  the  pyogenic  microbes  found  in  the  genito-urinary 
tract  to  be  practically  identic  with  the  lucteriurn  coli  commune.  Krogius 
found  among  seventeen  specimens  of  pathologic  urine  in  the  fluid  taken 
from  the  twelve  eases  an  organism  that  he  recognized  as  identic  with  pyo- 
genic bacteria  and  also  with  the  bacterium  cuti  commune.  In  eleven  cases 
this  bacillus  was  present  in  pure  culture.  He  afterward  found  this  organ- 
ism in  secondary  suppurative  processes  of  the  kidney,  and  also  in  the 
parenchyma  of  the  spleen.  Its  pyogenic  properties  were  proved  by  experi- 
mentation upon  animals. 

■  It  is  unnecessary  to  go  into  full  details  confirmatory  of  the  important 
relation  of  microbial  infection  to  the  local  and  general  toxemias  dependent 
upon  pathologic  conditions  of  the  genito-urinary  apparatus.  A  few  general 
considerations  are,  however,  essential: — 

That  the  gonococcus  is  an  important  factor  in  genito-urinary  infection 
has  been  proved  beyond  the  possibility  of  dispute.  That  it  is  so  important 
a  factor  as  Neisser,  Bumm,  and  others  assert  is  possibly  open  to  question — 
open  to  question  at  least  in  this  respect:  that,  if  it  be  claimed  that  without 
the  gonococcus  there  is  no  infection  of  the  urethral  mucous  membrane  or 
of  the  mucous  membrane  of  the  female  genitalia,  too  much  is  claimed  for 
that  micrb-organism,  and  too  little  respect  is  shown  for  other  micro-organ- 
isms that  thrive  in  the  female  genital  tract  and  which  may,  under  certain 
circumstances,  assume  pathogenic  properties.  It  is  the  author's  belief  that, 
through  evolutionary  changes,  what  may  be  termed  the  normal  micro- 
organisms of  the  female  generative  apparatus  may  undergo  transformations 


THE    GOXOCOCCUS    AS    A    FACTOE.  51 

and  assume  new  and  pathogenic  properties  not  only  capable  of  exciting 
urethral  inflammation  in  the  male,  but  under  favorable  circumstances — such 
as  are  afforded  by  the  traumatism  incidental  to  parturition — of  infecting 
the  female  herself.  There  is  one  point  that  has  probably  puzzled  others  as 
well  as  the  author.  Granting  that  gonorrhea  and  its  congeners  have  their 
origin  in  filthy,  unhealthy  states  of  the  female  genitalia,  it  remains  to 
account  for  the  origin  of  the  gonococcus.  Is  there  any  organism,  normally 
found  in  the  female  genital  apparatus,  that  may  undergo  transformation 
and  assume  the  properties  that  we  know  to  be  peculiar  to  the  gonococcus? 
Ur  is  the  starting-point  really  in  the  genital  apparatus  of  the  male,  the 
female  genitalia  acting  merely  as  the  culture-bed  for  the  evolution  of  the 
special  germ?  There  is  something  very  strildng  in  the  close  similarity  of 
the  gonococcus  and  the  normal  urethral  coccus.  The  question  is  an  open 
one  whether  the  gonococcus  is  not  really  a  derivative  of  urethral  and  vaginal 
cocci;  in  other  words,  whether  the  differences  existing  between  the  urethral 
coccus  and  the  gonococcus — such  differences,  for  example,  as  variation  in 
their  culture-media  and  properties  of  pathogenesis — might  not  be  accounted 
for  by  evolutionary  changes  in  these  innocuous  cocci.  The  special  proper- 
ties of  the  gonococcus  would  be  no  argument  against  this  possibility,  for, 
with  evolutionary  changes  of  form  and  adaptation  to  the  new  environment 
afforded  by  a  suppurative  inflammation  of  the  urethra,  it  is  not  illogical 
to  assume  that  the  acquirement  of  new  and  aj^parently  specific  properties 
might  result.  Even  in  cases  of  urethritis  that  are  distinctly  gonococcal  in 
origin,  or,  rather,  in  which  gonococci  are  present  in  great  numbers,  we  are 
confronted  with  a  mixed  infection.  The  periurethral  phlegmons  and 
aljscesses,  the  lymphangitis,  the  prostatic  suppurations,  the  acute  cystitis 
and  acute  inflammations  of  the  kidney,  and  in  women  the  peritonitis  that 
occurs  in  the  course  of  gonorrhea,  are  due,  not  to  infection  with  the  gono- 
coccus per  se,  but  to  other  germs  that  are  associated  with  it.  Gonococci, 
even  in  typic  gonorrhea,  rarely  exist  independently  of  common  pyogenic 
microbes,  certainly  not  after  the  first  few  days.  In  the  joint,  muscle,  ten- 
don, and  other  serious  complications  of  gonorrhea,  other  germs  than  gono- 
cocci— or  the  products  of  other  germs — are  usually  responsible  for  the 
condition.^  There  is  no  more  typically  mixed  infection  than  that  of 
gonorrhea. 

It  may  be  stated,  in  this  connection,  that  pus  from  periurethral  ab- 
scesses following  gonorrhea  has  been  inoculated  upon  the  urethral  mucous 
membrane  with  a  negative  result.  Ehrmann,  of  Vienna,  has  introduced 
pus  from  an  unopened  periurethral  abscess  into  a  blind  sac  of  mucous  mem- 
brane in  a  healthy  hypospadiac  without  effect.     The  introduction  of  this 


^  The   author   expressed   this   opinion   with   a   full   knowledge   of   the   fact   that 
gonococci  have  been  discovered  in  some  of  these  secondary  infections. 


52  EELATIOX    OF    BACTEEIOLOGY    TO    GEXITO-UEIXAEY    DISEASE. 

pus  into  the  urethra  of  the  same  individual  caused  only  a  slight  follicular 
inflammation  that  disapjjeared  in  a  few  days/ 

If  the  non-existence  of  a  specific  gonorrheal  cystitis  be  established,  it 
will  certainly  greatly  modify  the  existing  views  regarding  this  much- 
dreaded  complication  of  gonorrhea.  Even  prior  to  the  discovery  of  the 
gonococcus  it  was  supposed  that  gonorrheal  cystitis  was  due  to  specific 
infection:  i.e.,  to  the  specific  ''poison"  of  the  gonorrheal  process.  Since  the 
discovery  of  the  gonococcus  it  has  been  supposed  that  this  germ  was  the 
exciting  cause  of  complicating  cystitis.  Dumesnil,^  however,  denies  that 
there  is  such  a  thing  as  specific  gonorrheal  cystitis.  He  claims  that  when 
gonococci  are  found  in  the  urine  they  are  accidental  ingrafts  upon  the 
infectious  process,  having  entered  the  bladder  along  with  the  purulent 
products  of  the  urethral  inflammation.  They  are  not,  according  to  him, 
new  products  developed  from  true  specific  inflammation  of  the  vesical 
mucosa.  It  is  conceivable  that  in  women  urethral  or  vaginal  pus  often  gets 
into  the  bladder  in  this  manner,  but,  as  a  matter  of  fact,  so-called  gonorrheal 
cystitis  is  relatively  quite  rare  in  women.  Dumesnil  claims  to  have  deter- 
mined by  recent  researches  that  gonococci  produce  no  alteration  in  the  com- 
position of  urine,  cystitis  with  ammoniacal  urine  never  being  produced  by 
these  germs.  He  claims,  moreover,  that  the  constant  contact  of  the  urine 
either  renders  the  gonococci  harmless  or  kills  them  completely. 

Eegarding  the  evolutionary  theory  of  the  origin  of  the  local  venereal 
diseases, — which  will  be  again  alluded  to  in  connection  with  those  affec- 
tions, there  is  one  fact  that  seems  to  the  author  to  be  of  paramount  impor- 
tance, viz.:  if  we  accept  the  theory  of  evolution  as  applying  to  the  higher 
types  of  animal  and  vegetable  life,  we  must  necessarily  accept  it  as  applying 
to  germ-life,  the  difference  being  that,  while,  in  the  case  of  the  higher  animal 
and  vegetable  types  as  we  see  them  at  the  present  day,  differentiation  and 
adaptation  to  environment  are  going  on  slowly  if  at  all,  they  are  progressing 
in  a  most  marked  degree  in  the  lower  forms  of  life — to  such  a  degree  that  a 
distinct  variation  in  toxic  properties,  if  not  in  physical  form,  is  naturally  to 
be  expected.  One  thing  is  certain,  viz.:  if  we  accept  the  laws  of  evolution  as 
appMng  to  the  host — i.e.,  the  animal  infected — we  must,  nolens  volens. 
also  accept  it  as  applying  to  the  parasite:  i.e.,  the  microbe.  We  certainly 
produce  evolutionary  changes  in  the  germ,  so  far  at  least  as  its  vital 
properties  are  concerned,,  in  an  artificial  environment  of  our  own  creation 
in  the  laboratorj',  and  it  would  seem  that,  if  it  were  not  that  a  natural 
law  of  evolution  governs  micro-organisms — which  law  prevails  much  more 
powerfully  in   its   natural  habitat   than  in   our   culture-tubes — Ave   would 


^  Such  results  as  these,  however,  are  merely  suggestive.  The  discharge  of  a 
periurethral  abscess  into  the  urethra  is  quite  generally  followed  by  a  fresh  urethritis. 
The  mixed  character  of  the  infection  works  both  ways. 

-  Virchow's  Archiv.  vol.  cxxvi,  1891. 


EVOLUTION    OF    GENITO-UKIXAEY    IXFECTIOXS.  53 

have  absolutely  no  experimental  control  over  such  organisms.  The  only 
alternative  of  this  theory  is  the  view  of  a  special  creation  of  perfectly  de- 
veloped and  unvaryingly  typic  forms,  and  this  is  certainly  incompatible 
with  the  present  status  of  biology.  A  point  of  considerable  importance, 
bearing  upon  the  multiplicity  of  forms  discovered  by  different  observers  in 
various  infectious  genito-urinary  processes,  and  bearing  more  particularly 
upon  the  close  similarity  of  several  forms  of  microbes  thus  discovered,  is 
the  fact  that  the  physical  characteristics  of  a  germ  are  not  an  accurate  cri- 
terion of  its  special  qualities  of  infectiousness.  Germs,  the  form  and  alleged 
pathogenic  properties  of  which  are  precisely  similar,  have  been  found  in 
several  very  dissimilar  pathologic  processes,  suggesting  that  a  metamor- 
phosis of  the  germ  may  occur  by  virtue  of  which  it  acquires  a  variation  in 
its  properties  of  infectiousness  without  necessarily  undergoing  any  change 
in  physical  conformation. 

There  is  much  that  has  been  said  in  the  foregoing  general  survey  of 
genito-urinary.  infection  that  is  theoretic,  but  a  theory  based  upon  known 
laws  and  harmonizing  with  known  facts  contains  more  of  the  elements 
of  progress  than  a  passive  scientific  agnosticism  associated  with  a  mass  of 
crude  and  imperfectly  assimilated  clinical  and  experimental  observations — 
"bricks  without  straw" — that  signify  nothing  and  produce  nothing  save 
chaos  in  the  minds  of  those  who  develop  them. 


CHAPTEE  Y. 
General  Morbid  Phexomexa  Ixcidextal  to  the  Surgery 

OF    THE    GeXITO-UeINARY    OeGAXS. 

Urinary  or  Urethral  Fever. — This  is  an  omnibus  term  applied  to 
certain  morbid  phenomena  that  occasionally  result  from  operations  upon, 
or  diseases  of,  the  genito-urinary  tract.  These  phenomena  frequently  follow 
surgical  maneuvers  that  are  apparently  of  trivial  importance;  indeed,  a 
slight  operation,  such  as  simple  dilation  of  the  urethra,  may  produce  seri- 
ous results  even  where  severe  operations  are  well  borne. 

There  is.  great  discrepancy  in  the  opinions  of  various  authorities  re- 
garding the  pathology  of  the  polymorphous  disturbances  known  by  the 
various  terms  of  urethral,  urinary,  and  urine-  fevers.  This  is  because  these 
terms  are  applied  hap-hazard  to  several  distinct  types  of  morbid  phenomena, 
as  is  clearly  shown  by  a  careful  survey  of  the  clinical  facts. 

The  term  urethral  fever  has  been  made  to  cover  a  series  of  widely- 
var^ang  conditions.  The  term  urine-fever,  suggested  by  Eeginald  Harri- 
son, is  perhaps  the  most  accurate  as  applied  to  a  certain  type  of  cases, 
but  is  fallacious  because  suggestive  only  of  one  etiologic  factor.  Harrison 
is  of  opinion  that  the  so-called  urethral  fever  is  invariably  due  to  morbid 
changes  in  the  urine  at  the  site  of  injury,  developing  toxic  materials,  which, 
when  absorbed  into  the  circulation,  are  always  injurious  and  often  fatal. 
Whatever  its  etiology  may  be,  the  various  phases  of  this  complex  affection 
constitute  the  principal  danger  of  operations  or  injuries  of  the  genito- 
urinary tract. 

The  term  urethral  fever  has  been  made  to  include  conditions  bearing 
no  relation  to  each  other,  save  that  they  have  the  same  point  of  departure, 
viz.:  disease  or  injury  of  the  genito-urinary  tract.  Surgical  shock,  uremia, 
nervous  manifestations,  and  sepsis  following  genito-urinary  operations  are 
entirely  different  conditions.  They  may  exist  in  varying  combinations,  it 
is  true,  but  this  does  not  justify  an  omnibus  nomenclature.  Cases  in 
which  death  results  shortly  after  sounding,  and  classic  septemia  following 
genito-urinary  operations,  differ  widely  and  should  not  be  included  under 
any  general  head.  Bacteriologic  research  has  proved  many  of  the  cases 
hitherto  described  as  urethral  fever  to  be  due  to  germ-infection,  or  the 
absorption  of  germ-products.  This  should,  and  may  eventually,  govern 
their  nomenclature. 

Etiologically,  so-called  urethral  fever  embraces  the  following  forms 
of  morbid  phenomena,  capable  of  demonstration  in  typic  cases.  One  may 
merge  into  the  other;  all  are  secondary  to  genito-urinary  operations, 
chronic  disease,  or  injury. 

(54) 


URIXARY    OR    URETHRAL    FEYER.  55 

1.  The  first  and  simplest  form  is  nervous  rigor  not  succeeded  hy  fever, 
following  shortly  after  ojDerations  or  injury.  It  is  probably  due  to  slight 
shock,  with  resultant  peripheral  vasomotor  disturbance. 

2.  Traumatic  or  surgical  fever  (ferment-fever),  due  to  excessive  reac- 
tion from  shock — perverted  metabolism — in  combination  with  decomposi- 
tion of  fibrin  ferments.  This  is  likely  to  be  modified  by  a  varying  degree 
of  septic  infection. 

3.  Toxemia  foUoiving  severe  shoch  with  resultant  perverted  elaboration 
of  the  urinary  secretion  and  the  formation  of  organic  poisons  similar  to  the 
vegetable  alkaloids.  Associated  with  this  is  reflex  inhibition  of  the  renal 
function  with  uremia  and  perversion  of  general  tissue-metabolism.  This 
is  the  typic  urinary  fever.     It  is  sometimes  complicated  by  convulsions. 

4.  Septemia,  or  sapremia,  which  may  be  speedily  fatal,  or  merge  into 
general  pus-infection  with  circumscribed  and  diffuse  suppurations  in  various 
parts.  The  latter  may  supervene  without  the  characteristic  phenomena  of 
ordinary  sepsis. 

5.  Typic  pus-infection,  due  to  pyogenic  microbes  of  various  forms. 

().  Chronic  urinary  fever  (chronic  urinary  toxemia)  attendant  upon 
long-standing  obstructive  urinar}'  disease. 

7.  Cases  of  mixed  type  combining  in  varying  degrees  various  elements 
of  the  preceding  types  of  disease. 

If  the  foregoing  classification  be  clinically  or  even  pathologically  justi- 
fiable, the  variation  of  opinion  regarding  the  pathology  of  urinary  fever  is 
not  surprising. 

There  must  be  some  explanation  for  the  fact  that  one  authority  claims 
that  these  varying  phenomena  are  invariably  septic,  another  that  they  are 
due  to  ammoniacal  decomposition  of  urine  and  absorption  of  the  products, 
another  that  they  are  due  to  simple  uremia,  and  last,  but  not  least,  that 
they  are  clue  to  obscure  changes  in  the  urinary  secretion  and  the  formation 
of  new,  and  as  yet  unisolated,  toxic  compounds.  It  is  evident  to  every 
practical  surgeon  that  none  of  these  causes  is  sufficient  to  explain  all  of 
the  cases  of  so-called  urethral  fever.  Simple  absorption  of  healthy  urine 
will  not  produce  injury.  It  has  been  shown  that  normal  urine  will  not 
even  produce  suppuration  when  injected  hypodermically.  Decomposed 
urine,  however,  has  most  powerful  propensities  for  evil;  in  fact,  there  is 
hardly  any  organic  substance  that  is  so  destructive  to  cellular  tissue.  Ex- 
perience with  cases  of  urinary  extravasation  substantiates  this.  There  is  a 
close  resemblance  between  the  effects  of  extravasation  of  decomposing  urine 
and  those  of  the  poisons  of  erysipelas,  dissecting  wounds,  and  even  the  bite 
of  venomous  reptiles,  as  regards  their  effects  upon  connective  tissue. 

It  is  obvious  that  in  all  cases  of  injury  or  operations  of  the  urinary 
organs  there  is  great  danger  of  septic  infection.  The  site  of  the  injury  is 
usually  such  that  free  drainage  is  impossible;  decomposing  urine  is  usually 
present,  producing  more  or  less  wide-spread  death  of  connective  and  cellular 


56  GENEEAL    PHE^^OMEXA    IN    GEXITO-rEINARY    SUEGEEY. 

tissue,  and  there  always  prevail  the  conditions  of  heat  and  moisture.  Such 
an  environment  is  peculiarly  favorable  to  the  development  of  the  germs  upon 
which  septemia  and  its  congeners  depend. 

ISTone  of  the  pathologic  views  thus  far  advanced  will,  when  taken  alone, 
explain  the  fatalities  occasionally  resulting  from  the  introduction  of  a 
smooth  sound. ^  It  is  worthy  of  note  that  a  simple  straight  cut  in  the 
urethra — as  in'  internal  urethrotomy — often  produces  less  shock  than 
stretching  the  sensitive  stricture  by  bougies.  Irritable,  sensitive,  con- 
tractured  tissues  in  any  situation  are  always  more  safely  and  comfortably 
dealt  with  by  complete  division  than  by  repeated  attempts  at  stretching. 

The  benefits  of  gradual  dilatation  in  stricture  depend  upon  (1)  me- 
chanic distension;  (2)  reactionary  hyperemia,  with  increased  local  tissue- 
change.  The  activity  of  the  lymphatics  and  veins  is  increased,  and  ab- 
sorption is  very  rapid.  If  the  tissues  be  extraordinarily  sensitive  or  if  toxic 
principles  from  decomposing  urine  or  ordinary  septic  materials  be  present 
at  the  site  of  the  stricture  or  behind  it,  dilation  must  necessarily  produce, 
first,  a  degree  of  nervous  shock  dependent  upon  the  susceptibility  of  the 
individual  and  the  roughness  of  manipulation;  second,  a  varying  degree 
of  absorption  of  morbific  materials.  The  lymphatics  and  veins,  unfortu- 
nately, do  not  discriminate  between  poisonous  and  non-poisonous  sub- 
stances; they  therefore  take  up  the  poisonous  materials  simultaneously  with 
the  products  of  retrograde  tissue-change  and  thereby  infect  the  general  sys- 
tem. 

The  relation  of  organic  and  functional  renal  disturbance  to  so-called 
urethral  fever  is  most  intimate.  No  case  of  long-standing  obstructive  dis- 
ease of  the  genito-urinary  tract  is  unaccompanied  by  functional  aberration 
of  the  kidneys.  In  a  large  proportion  of  cases  organic  changes  finally 
occur.  This  is  to  be  anticipated  and  given  serious  consideration.  The  im- 
mediate effects  may  not  be  marked,  because  of  vicarious  elimination  by  the 
skin  and  bowels:  constituting  the  means  by  which  the  system  accomodates 
itself  to  imperfect  elimination  of  the  constituents  of  urine.  There  are  few 
persons  whose  bodily  sewage  is  perfect,  and,  if  the  kidneys  perform  their 
functions  imperfectly,  this  condition  of  imperfect  sewage  assumes  vital  im- 
portance. When  genito-urinary  operations  produce  shock,  reflex  renal 
hyperemia  is  apt  to  result.  This  causes  a  strain  upon  the  renal  circulation 
that  its  impaired  condition  cannot  withstand.  As  a  result,  its  functions  are 
completely  inhibited  and  uremia  follows. 

To  those  familiar  with  nerve-physiology  in  its  more  intimate  relations 
to  visceral  functions,  the  association  of  reflex  irritation  and  renal  aberra- 
tion should  not  be  surprising,  yet  this  particular  phase  of  neuro]3athology 
is  seldom  accorded  the  prominence  it  deserves.    Many  interesting  examples 


^  Recent    writers — germ-aiid-toxin    mad — ignore    all    of    the    old-fashioned,    but 
accurate,  clinical  obsei-^-ations  of  these  cases. 


EELATION    OF    EENAL    DISEASE    TO    UEIXAKY    FEYEE.  57 

of  urinary  suppression  from  reflex  inhibition  of  the  renal  function  have 
been  observed. 

Peyrani  has  shown  that  the  sympathetic  nerves  have  a  remarkable 
influence  over  the  secretion  of  urine,  galvanization  of  these  nerves  increas- 
ing the  amount  of  urine  and  urea,  while  section  of  them  causes  both  urine 
and  urea  to  sink  to  a  minimum. 

There  is  abundant  proof  of  the  relation  of  renal  disturbances — and 
especially  albuminuria — to  reflex  irritation.  Eenal  aberration  is  most  liable 
to  occur  from  operations  in  certain  special  regions — notably  the  abdomen 
and  genito-urinary  organs.  This  is  explained  by  the  intimate  relation  of 
the  sympathetic  ganglia  (through  their  visceral  filaments  of  distribution) 
with  the  nervous  supply  of  these  regions.  Nowhere  are  the  cerebro-spinal 
and  sympathetic  systems  more  closely  associated.  This  being  understood, 
it  is  not  remarkable  that  injuries  of  these  parts  should  cause  reflex  dis- 
turbance of  correlated  organs,  even  though  distant.  The  functions  and 
physiologic  integrity  of  the  abdominal  and  pelvic  viscera  are  dominated 
by  the  solar  plexus,  the  kidneys  being  intimately  associated  with  the  other 
organs  through  the  renal  plexus,  the  component  parts  of  which  are  fila- 
ments from  the  solar  and  aortic  plexuses,  semilunar  ganglia,  and  lesser 
splanchnic  nerves.  Passing  into  the  renal  substance  from  the  renal  plexus 
are  some  fifteen  or  twenty  nerve-filaments  with  numerous  associated 
ganglia  accompanying  the  arteries.  The  multitudinous  distribution  of  these 
filaments  to  the  parenchyma  and  blood-vessels  of  the  kidneys  has  been  well 
described  b)''  Holbrook.  The  renal  nerve-tissues  are  principally  non- 
medullated,  sometimes  surrounding  the  arteries  in  immense  numbers;  en- 
circling them  around,  above,  and  below;  freely  branching,  bifurcating, 
and  supplying  all  of  the  neighboring  structure  with  numerous  delicate 
fibrils;  a  plexus  encircling  every  tubule;  supplying  the  connective  tissue 
extending  into  the  layer  known  as  the  memhrana  propria,  and  even  piercing 
this  structure  and  penetrating  into  the  epithelia  and  the  cement-substance 
between  them.  The  nerves  also  give  off  delicate  ramifications  to  the  afferent 
blood-vessels,  entering  the  vascular  tufts  and  producing  a  delicate  plexus 
around  the  capillaries.  The  distribution  of  nerves  is  richer  in  the  con- 
voluted and  narrow  tubules  than  in  the  straight  collecting  tubes. 

Eeasoning  from  the  foregoing  anatomic  facts,  it  is  easy  to  understand 
how  irritations  of  the  abdominal  and  pelvic  viscera  or  genito-urinary  organs 
may  be  reflected  to,  and  produce  morbific  changes  in,  the  kidneys.  Hardly 
a  case  of  genito-urinary  disease,  perhaps,  runs  its  course  without  a  certain 
degree  of  this  refiex  impression.  The  result  depends  chiefly  upon  the 
organic  state  of  the  kidneys;  if  this  be  bad,  speedy  death  may  result.  All 
operative  manipulations  of  the  genito-urinary  tract  are  liable  to  concuss, 
so  to  speak,  the  renal  nerve-supply:  i.e.,  are  likely  to  bring  a  reflex  strain 
upon  the  blood-vessels,  disturbing,  secondarily,  the  nutrition  of  the  kidneys. 
Autogenesis  in  its  relations  to  the  development  of  certain  constitutional 


58  GENERAL    PHENOMENA    IX    GEXITO-UEIXAEY    SURGEKY. 

conditions  demands  more  attention  than  is  usually  accorded  it.  and  it  is 
probable  that  physioehemic  researches  in  this  direction  will  in  future 
shed  new  light  upon  many  diseases  the  etiology  of  which  is  now  obsctire. 
Among  the  modern  writers  who  have  given  attention  to  the  morbid  results 
of  perverted  physiologic  chemistry,  Benjamin  Ward  Eichardson  is,  perhaps, 
the  most  prominent.  It  is  to  the  researches  of  this  author  that  we  are 
indebted  for  the  most  widely  accepted  theory  of  the  pathology  of  rheuma- 
tism. 

It  is  probable  that  perverted  tissue-metabolism  bears  a  causal  relation  to 
the  typic  cases  of  urethral  fever.  This  perverted  physiochemism  may  l)e 
readily  brought  about  by  stirgical  shock,  and  is  especially  marked  in  glandu- 
lar tissues.  We  know  quite  well  that  mental  emotions  of  various  kinds 
and  those  impressions  upon  the  nervous  system  that  result  in  shock  may 
produce  marked  changes  in  the  various  physiologic  secretions,  consisting 
of  increased  or  diminished  flow  or  obscure  cliemic  changes  of  composition; 
thus,  various  nervous  impressions  may  cause  increase  or  decrease  of  saliva, 
lacteal  secretion,  gastro-intestinal  secretions,  urine,  and  the  menstrual  flow. 

A  familiar  illustration  of  the  chemic  effect  of  emotions  upon  physio- 
logic secretions  is  the  change  in  the  quality  of  the  lacteal  secretion  induced 
by  fright,  anger,  or  grief.  This  change,  although  occult  and  incapable  of 
demonstration  by  microscopic  or  chemic  research,  is  very  pronounced  in  its 
morbid  eff'ects  upon  the  child,  cholera  infantum  of  a  most  fatal  character 
being  a  frequent  sequel  to  the  emotion  of  anger  in  the  mother.  Precisely 
what  this  change  in  chemic  composition  may  be  is  an  open  question,  but  it 
is  possibly  a  species  of  decomposition  resulting  in  the  formation  of  a  poison 
analogous  to  the  "tyrotoxicon"  discovered  by  Vaughn  in  impure  cows"  milk. 
It  is  well  known  that  great  care  is  necessary  on  the  part  of  those  who  sup- 
ply milk  for  the  use  of  infants  to  prevent  fatigue  and  various  sources  of 
excitement  in  the  cows  from  which  it  is  taken.  Sexual  excitement  in  the 
cow  catises  changes  in  the  milk  that  may  render  it  unfit  for  human  food. 

If  the  changes  alluded  to  occur  in  one  secretion,  it  is  probable  that 
all  of  the  physiologic  secretions  are  susceptible  to  them.  In  the  case  of 
the  saliva,  for  example,  the  emotion  of  anger  may  ^jossibly  cause  the  de- 
velopment of  toxic  principles  in  that  secretion  that  explain  the  serious  re- 
sidts  which  so  often  ensue  from  the  bite  of  an  enrasfecl  human  being. 

The  difficulty  of  proving  this  theory  in  the  present  state  of  our  knowl- 
edge of  physiologic  chemistry  is  obvious. 

In  the  case  of  the  urine  the  influence  of  surgical  shock  may  he  in- 
ferred to  consist  in  the  development  of  organic  poisons — toxins — in  that 
secretion.  These  may  be  considered  to  be  hypothetically  analogous  to  the 
ptomains  and  leucomains  found  in  both  dead  and  living  bodies,  and  which 
so  closely  resemble  the  vegetable  alkaloids,  particularly  nicotin.  brucin,  and 
strychnin.  Eeginald  Harrison  also  believes  that  such  compounds  may  de- 
velop in  the  urine,  under  certain  circumstances.     The  toxemia  resulting 


PEKYERTED  METABOLISM  IX  UKIXAEY  FEVEE.  59 

from  snch  changes  will  perhaps  explain  some  of  the  otherwise  ohscure  and 
mysterious  cases  of  death  following  the  simple  introduction  of  a  sound. 

It  is  a  noteworthy  fact,  in  this  connection,  that  in  many  cases  it  is 
not  until  the  urine  comes  in  contact  with  a  urethral  wound  tliat  chill  or 
febrile  action  result.  Thus,  if  an  operation-wound  he  made  in  the  anterior 
urethra  no  disturbance  may  result  ifntil  the  patient  urinates  for  the  first 
time  after  operation.  AAlien  the  urine  is  diverted  from  the  wound  by  the 
insertion  of  a  vesical  drain  through  the  perineum,  urinary  fever  does  not 
result,  as  a  rule.^ 

In  some  cases  the  development  of  uremia  or  toxemia  is  very  gradual, 
coming  on  only  after  successive  operations  upon  the  genito-urinary  tract. 
The  poisonous  materials  may  accumulate  in  the  system  for  some  time  and 
their  presence  fail  to  manifest  itself  until  the  system,  so  to  speak,  is  sur- 
charged with  them  and  ready  for  an  explosion,  when  a  previously  well- 
tolerated  and  comparatively  slight  irritation  of  the  genito-urinary  appa- 
ratus will  he  sufficient  to  develop  serious  results.- 

The  following  case  illustrates  the  point  just  made: — 

Case. — A  competent  surgeon  of  this  city  i^erformed  urethrotomy  upon  an  appar- 
ently healthy  young  man  28  years  of  age.  The  stricture  was  located  about  three- 
fourths  of  an  inch  posterior  to  the  meatus  and"  was  divided  under  cocain  without  diffi- 
culty or  pain.  Each  subsequent  operation  of  dilation  was  preceded  by  the  injec- 
tion of  4-per-cent.  solution  of  cocain,  the  quantity  used  being  about  2  fluidrams.  A 
week  after  the  urethrotomy  the  patient  complained  of  nervousness  and  insomnia, 
which  was  not  considered  important.  On  the  ninth  day  an  attempt  was  made  to  per- 
form the  usual  operation  of  sounding  and  injection  of  cocain,  the  patient  meanwhile 
lying  on  an  ordinaiy  surgical  chair.  The  surgeon  left  the  patient  for  a  moment  to 
procure  a  sound  and  give  the  cocain  an  opportunity  to  act.  He  was  called  back 
in  about  a  minute  by  the  patient,  who  complained  of  dizziness  and  immediately  fell 
back  in  the  chair  in  convulsions.  Assistance  was  called,  stimulants  were  given,  and 
the  galvanic  current  used,  but  without  avail,  the  patient  dying  within  five  minutes. 

At  the  post-mortem  a  thorough  examination  of  all  the  vital  organs 
was  made,  but  everything  was  found  perfectly  healthy,  with  the  exception 
of  the  kidneys,  which  were  extremely  congested,  presenting  a  bluish  appear- 
ance similar  to  that  of  the  spleen.  This  fatal  result  was  evidently  not 
attributable  to  the  cocain,  but  due  to  the  sudden  explosion  of  poisonous- 
materials  that  had  been  gradually  accumulating  in  the  s)'stem  as  a  con- 
sequence of  inhibition  of  the  renal  functions  and  the  metabolic  action  of 
slight  surgical  shock  upon  the  tissues.  This  toxemia  gradually  increased 
and  finally  became  so  severe  that  comparatively  slight  irritation  was  suffi- 
cient to  precipitate  a  nervous  explosion.     The  irritation  was  afforded  by 


^  HaiTison  insists  on  this  point  much  too  emphatically.  Some  cases  develop  chill 
immediately  after  sounding,  and  before  urine  has  been  passed. 

=  The  late  Sir  Andrew  Clark  also  suggested  that  '-'catheter-fever'^  might  be  due 
to  some  nutritive  disturbance  produced  by  reflex  nervous  influences. 


60  GENERAL    PHENOMENA   IN    GENITO-URINARY    SURGERY. 

the  mechanic  effect  of  the  injection  of  cocain,  and  it  is  probable  that  the 
introduction  of  simple  water  would  have  had  a  similar  effect.  The  analog-y 
to  an  epileptic  seizure  at  once  suggests  itself. 

The  danger  of  development  of  urinary  fever  is  directly  proportionate  to 
the  depth  of  traumatic  and  surgical  injuries  of  the  urethra, — i.e.,  to  their 
distance  from  the  meatus.  Those  situated  in  the  pendulous  portion  are  not, 
as  a  rule,  very  dangerous  as  compared  with  those  that  occur  in  the  fixed 
or  deep  portion.  This  is  easily  explained:  the  nerve-supply  of  the  deep 
urethra  is  much  more  liberal  and  sensitive,  the  cellular  tissue  more  abun- 
dant, and  the  opportunities  for  drainage  much  less  favorable  than  in  the 
pendulous  portion.  Decomposing  urine  is  not  so  likely  to  remain  behind  a 
stricture  in  the  pendulous  portion,  because  of  simple  gravity  and  the  fact 
that  such  strictures  are  usually  of  large  caliber.  Urinary  extravasation  in 
the  pendulous  urethra  is  not  apt  to  produce  serious  danger  to  life;  the 
connective  tissue  in  this  situation  is  very  sparse  and  the  extravasated  fluid 
is  likely  to  be  detected  before  it  has  burrowed  back  into  the  perineum. 

The  relation  of  germ-infection  and  absorption  of  the  products  of  germ- 
evolution  to  the  septic  varieties  of  so-called  urethral  fever  is  a  most  im- 
portant one.  This  is  proved  by  the  researches  of  investigators  whose  testi- 
mony is  unimpeachable. 

The  clinical  features  of  the  various  morbid  general  phenomena  that 
may  result  from  surgical  manipulations  of  the  genito-urinary  tract  demand 
special  consideration: — 

The  nervous  form  of  the  disease  usually  appears  in  patients  of  an  im- 
pressionable constitution:  i.e.,  those  who  present  a  decided  neuropathic 
tendency.  Its  occurrence  may  often  be  anticipated  from  the  patient's  be- 
havior under  instrumentation.  He  may  have  nausea,  perhaps  vomiting, 
slight  rigors,  partial  or  complete  orgasm,  or  more  or  less  complete  syncope 
as  the  instrument  penetrates  the  deep  urethra.  Such  patients  are  likely  to 
develop,  as  a  rule,  a  sharp  chill  within  twenty-four  hours  after  urethral 
operations  or  injuries.  This  lasts  for  a  variable  time,  is  rarely  prolonged, 
and  when  it  passes  off  leaves  the  patient  about  as  well  as  before,  with  the 
exception,  perhaps,  of  more  or  less  mental  depression.  Earely,  indeed,  there 
may  be  a  slight  amount  of  fever  or  sweating.  The  chill  may  come  on 
within  a  very  few  minutes  after  the  operation. 

The  traumatic  form  is  the  most  common.  This  is  ushered  in  by  a  sharp 
chill,  usually  within  twenty-four  hours  after  operations  or  injuries  of  the 
genito-urinary  tract,  and  is  followed  by  sharp  fever  succeeded  by  sweating. 
The  disturbance  either  passes  off  after  a  single  paroxysm,  or  is  followed 
by  a  period  of  general  malaise,  with  perhaps  a  recurrence  of  the  paroxysms 
for  several  days.  In  these  latter  cases  there  is  present  in  all  probability  a 
slightly  septic  element. 

Typic  urine-fever — the  most  frequent  variety — may  or  may  not  be 
attended  by  a  violent  chill  coming  on  within  twelve  to  thirty-six  hours. 


VARIETIES    OF    URINARY    FEVER.  61 

There  are  marked  prostration,  violent  vomiting  and  diarrhea,  coldness  of 
the  skin, — succeeded  later  on  by  more  or  less  febrile  movement  of  tempera- 
ture, if  the  patient  survives, — with  suppression  of  urine,  merging  in  a  very 
short  time  in  fatal  cases  into  coma  of  an  apparently  uremic  type.  The 
author  describes  the  coma  as  of  "apparently  uremic  type"  because,  accord- 
ing to  the  theory  advanced  regarding  the  action  of  shock  upon  the  urine, 
there  is  probably  present  in  many  cases  a  toxic  element  that  is  independent 
of  ordinary  uremia.  This  condition  may  develop  gradually,  manifesting 
itself  by  a  sudden  explosion  in  the  form  of  convulsions,  as  illustrated  by 
the  fatal  case  that  has  just  been  related. 

8&ptemic  fever  of  genito-urinary  origin  usually  begins  by  slight  (but 
sometimes  very  severe)  chill;  this  is  followed  by  fever  of  varying  degree 
of  severity.  The  infection  may  be  very  acute,  the  patient  sinking  into  a 
typhoid  condition,  or  becoming  comatose  and  dying  within  from  two  to 
ten  days.  Again,  the  condition  may  be  subacute,  merging  into  general 
pus-infection,  known  familiarly  as  pyemia.  In  the  latter  event  the  patient 
finally  succumbs  to  the  slow  development  of  circumscribed  or  diffuse  puru- 
lent deposits  in  the  joints,  viscera,  and  other  structures  of  the  body,  due 
to  infection  with  pyogenic  microbes  and  their  products. 

The  chronic  form  of  urine-fever  is  a  chronic  condition  of  toxemia  and 
nervous  irritation  produced  by  long-continued  obstructive  and  inflamma- 
tory affections  of  the  genito-urinary  tract.  This  condition  of  toxemia  and 
general  nervous  irritation  is  not  generally  recognized,  but  is  very  important 
in  its  relations  to  chronic  genito-urinary  disease.  It  exists  in  the  majority 
of  cases  of  organic  stricture  of  long  standing,  in  old  men  with  prostatic 
hypertrophy,  in  tumors  of  the  bladder,  in  chronic  cystitis  from  any  cause, 
and  in  pyelitis,  especially  the  variety  due  to  nephritic  calculi.  Patients 
suffering  with  these  affections  have  a  tendency  to  mild  hectic  fever;  flushing 
of  the  face  with  slight  elevation  of  temperature,  perhaps  followed  by  a 
certain  degree  of  perspiration,  is  quite  common;  nervous  irritability  is  espe- 
cially marked.  Indeed,  there  are  few  conditions  that  are  productive  of  so 
much  mental  depression  and  irascibility  as  chronic  diseases  of  the  genito- 
urinary tract.  The  sufferer  from  vesical  calculus,  prostatic  hypertrophy, 
or  stricture  is  apt  to  be  unreasonably  morose  and  irritable.  More  or  less 
obscure  rheumatic  or  neuralgic  pains  in  various  situations  may  also  be 
present.  After  prolonged  retention  of  urine  from  any  cause  the  majority 
of  patients  suffer  for  a  few  days  or  weeks  from  more  or  less  elevation  of 
temperature. 

The  different  general  canditions  that  have  been  outlined  are  probably 
mainly  due  to  toxemia  dependent  upon  (a)  imperfect  elimination  of  the 
products  of  retrograde  tissue-metamorphosis;  (b)  a  greater  or  less  degree 
of  absorption  of  morbific  materials, — i.e.,  pseudo-alkaloid  germ-products, — 
produced  by  inflammation  and  the  decomposition  of  residual  urine  behind 
the  site  of  obstruction.     It  will  be  observed  that  many  patients  suffering 


62  GENERAL    PHENOMENA    IN    GENITO-URINARY    SURGEEY. 

from  clironic  obstructive  genito-iirinary  disease  do  not  realize  how  ill  they 
are  until  the  local  disease  has  been  removed  or  at  least  greatly  improved; 
they  then  find  that  slight  disturbances  to  which  they  had  paid  comparatively 
little  attention  and  which  they  had  not  in  the  least  attributed  to  their 
urinary  trouble  have  disappeared.  This  is  due,  in  great  measure,  to  the 
removal  of  reflex  nervous  irritation,  but,  more  than  this,  to  the  fact  that 
the  constant  absorption  of  poisonous  materials  from  the  site  of  disease  has 
been  stopped. 

Tlie  mia'ed  form  of  so-caUed  urethral  fever-  is  not  so  distinct  an  entity  as 
the  preceding  varieties.  There  are  relatively  few  cases  that  cannot  be 
assigned  to  one  or  the  other  of  the  varieties  of  disturbance  already  described. 
Cases  occasionally  occur,  however,  in  which  there  exists  in  varying  pro- 
portions evidence  of  both  septic  or  pus  absorption  and  uremia,  Avith  pos- 
sibly a  tendency  to  disturbance  of  the  nervous  functions.  A  clinical  differ- 
entiation might,  in  such  cases,  be  impracticable. 

It  is  obvious,  from  the  foregoing  survey  of  clinical  and  pathologic 
facts,  that  the  range  of  cases  which  can  justly  be  designated  as  urethral, 
urine,  or  urinary  fever  is  rather  limited.  Those  cases  resulting  from  sep- 
temia  and  surgical  shock  certainly  cannot  consistently  be  so  classified. 

It  has  been  the  author's  experience  that  patients  suffering  from  paludal 
poisoning  are  especially  apt  to  develop  chill,  and  often  fever,  after  genito- 
.urinary  manipulations. 

In  cases  in  which  a  general  anesthetic  is  given,  it  is  always  well  to  in- 
quire into  the  responsibility  of  the  anesthetic  per  se.  The  anesthetic  is  often 
a  direct  cause  of  renal  disaster  following  genito-urinary  operations.  Ether 
is  far  more  dangerous  than  chloroform  in  this  respect.  If  this  were  gen- 
erdly  understood,  chloroform  would  be  far  more  popular  than  at  present. 
Chloroform  kills  in  such  an  unmistakable  fashion  that  he  who  runs  may 
read,  and  never  fails  to  receive  due  credit  for  accidents.  Ether,  however, 
while  permitting  the  patient  to  get  off  the  operating-table,  often  destroys 
life  several  days  later  by  acute  renal  congestion,  or,  perchance,  acute 
nephritis. 

Urinary  chill  and  fever  are  infrequently  met  with  unless  there  is  a 
lesion  of  the  mucous  membrane,  showing  that  the  cause  in  a  large  proportion 
of  the  cases  in  which  evil  results  from  genito-urinary  operations  is  absorption 
of  some  toxic  material. 

Xo  matter  Avhat  view  he  may  take  of  the  etiology  of  the  various  forms 
of  urinary  fever,  the  surgeon  is  always  confronted  by  three  possible  elements 
of  pathogenesis  in  such  cases:  (1)  an  impression  of  a  purely  nervous  char- 
acter, (2)  toxemia  due  to  absorption  of  septic  materials,  and  (3)  toxemia  pro- 
duced by  retention  in  the  blood  of  the  products  of  retrograde  tissue- 
metamorphosis  incidental  to  inhibition  of  the  renal  function  of  the  kid- 
neys, which,  in  lieu  of  a  better  term,  we  call  uremia.  These  pathologic 
factors,  as  already  noted,  may  exist  singly  or  combined. 


TREATMENT  OF  URINARY  FEVER.  63 

Treatment. — The  principal  measures  of  treatment  of  the  morbid  phe- 
nomena following  genito-urinary  operations  are  of  a  prophylactic  character 
for,  unfortunately,  the  marked  forms  of  the  disease — i.e.,  the  septic  and 
uremic  varieties — are  seldom  recovered  from.  The  principal  feature  of 
prophylaxis  should  consist  of  strict  attention  to  the  principles  of  genito- 
urinary hygiene.  If  the  functions  of  the  kidney  are  stimulated  by  alkaline 
diuretics,  and  the  skin  and  bowels  kept  in  an  active  condition,  thus  afford- 
ing vicarious  relief  to  the  kidney,  the  patient  is  placed  in  the  best  possible 
condition  to  avoid  the  accidents  and  complications  that  have  been  described. 
In  addition  to  these  measures,  antiseptics  should  be  given  internally  prior 
to  operations.  Of  these,  boric  acid,  cystogen,  diuretin,  and  salol  are  among 
the  most  popular.  The  author's  preference  is  for  the  oil  of  eucalyptus  in 
doses  of  10  minims.  Salicylic  acid  or,  preferably,  salicylate  of  soda  is  also 
serviceable. 

Local  antisepsis  in  cases  of  chronic  bladder  and  prostatic  disease  is,  of 
course,  essential.  It  can  be  best  accomplished  by  irrigation  with  mild  anti- 
septic solutions,  such  as  carbolic  acid,  sodium  biborate  or  boric  acid,  potas- 
sium permanganate,  and  mercury  bichlorid.  Operations  upon  cases  com- 
plicated by  structural  renal  disease  should  be  avoided  if  possible.  Where 
operation  is  unavoidable  the  surgeon  should  not  only  be  very  careful  in  his 
manipulations,  but  should  lay  the  unfavorable  features  of  the  case  frankly 
before  the  patient  and  his  friends.  Immediately  prior  to  operative  inter- 
ference, in  eases  of  serious  import,  particular  attention  should  be  paid  to 
the  function  of  the  kidneys  and  local  antisepsis.  The  patient  should  be  put 
to  bed  and  kept  perfectly  quiet,  and  put  upon  a  milk  diet  with  moderate 
doses  of  quinin,  3  to  5  grains  thrice  daily,  for  a  week  or  ten  days  previous  to 
the  operation. 

Various  drugs  have  been  recommended  for  administration  just  before 
or  at  the  time  of  urinary  manipulations  or  operations.  Quinin  and  mor- 
pliin  in  10-  and  ^/^-grain  doses,  respectively,  are  popular  remedies  and  un- 
questionably have  a  proj)hylactic  effect  by  increasing  the  resisting  power  of 
the  nervous  system,  thus  lessening  liability  to  shock.  Jaborandi  is  also  rec- 
ommended for  this  purpose,  and  inasmuch  as  its  physiologic  action  is  such 
that  it  must  necessarily  relieve  strain  upon  the  kidney,  the  drug  would 
appear  to  be  one  of  our  most  philosophic  remedies.  Hypodermic  injections 
of  ^/g  to  ^/g  grain  of  pilocarpin  muriate  may  be  given  instead  of  the  fluid 
extract  of  jaborandi.  Should  uremia  supervene,  this  method  of  adminis- 
tration is  absolutely  essential. 

The  milder  cases  of  general  disturbance  (the  nervous  and  traumatic 
forms)  are  rarely  fatal,  but  may  possibly  merge  into  the  severer  types,  and 
consequently  demand  attention.  The  administration  of  opium  and  jabo- 
randi, with,  perhaps  (in  the  traumatic  form),  aconite  or  veratrum  viride, 
constitutes  the  'best  treatment  at  our  command. 

When  uremia  occurs,  attention  should  first  be  directed  to  the  vicarious 


64  GEISTERAL    PHENOMEXA    IN    GEiv'ITO-URIX ARY    SUEGEEY. 

elimination  of  urea.  Valuable  time  must  not  be  wasted  in  attempting  to 
restore  the  function  of  the  kidneys  immediately  after  the  supervention  of 
uremia,  particularly  if  coma  develops.  Pilocarpin  given  hypodermically  is 
effective  in  inducing  perspiration,  even  when  the  patient  is  comatose,  and 
should  be  given  freely.  The  bowels  should  be  moved  by  croton-oil,  2  or  3 
drops  of  which  in  combination  with  5  or  6  drops  of  olive-oil,  may  be  placed 
upon  the  back  of  the  tongue.  If  the  patient  is  able  to  swallow,  elaterium 
in  the  dose  of  from  Vs  to  Vs  grain  is  preferable  to  all  other  hydragogic 
cathartics.  Hot  baths  should  be  given  and  dry  or  wet  cups  applied  over 
the  region  of  the  kidneys.  Digitalis  and  saline  diuretics  may  be  given 
internally  after  the  emergency  is  over,  but  it  is  bad  practice  to  attempt  to 
accomplish  anything  by  diuretics  before  vicarious  elimination  of  urea  has 
been  attended  to.  It  is  also  questionable  whether  stimulation  of  the  renal 
function  is  safe  practice  before  an  attempt  at  derivation  has  been  made. 

Urethral  irrigations  with  solutions  of  mercury  biehlorid,  1  in  20,000, 
before  and  after  manipulations  of  the  canal,  will  usually  prevent  septic 
infection  after  genito-urinary  manipulations. 

Modern  measures  to  insure  asepsis  of  urethral  instruments  constitute 
an  important  means  of  prophylaxis  of  sepsis.  Before  being  used  the  asep- 
tized  sounds  and  other  instruments  should  be  carefully  warmed,  and  luljri- 
cated  with  some  antiseptic  substance;   they  should  also  be  perfectly  smooth. 

Metallic  instruments  are  more  liable  to  produce  chill  and  subsequent 
manifestations  of  urinary  fever  than  are  the  soft  varieties.  The  probable 
explanation  is  that  soft  instruments  are  used  in  comparatively  small  sizes 
and  their  introduction  is  so  easy  that  it  would  be  a  bungling  operator 
indeed  who  could  succeed  in  producing  injury;  whereas  even  in  skilled 
hands  the  use  of  the  steel  sound  or  metallic  catheter  is  likely  to  produce  a 
relatively  marked  disturbance  both  of  normal  and  pathologic  mucous  mem- 
brane. 

When  septemia  or  pyemia  develops  despite  all  precautions,  very  little 
can  be  done,  as  a  rule,  beyond  supporting  the  vital  powers  by  free  stimula- 
tion, a  fatal  result  being  almost  inevitable.  An  attempt  to  avert  a  fatal 
result  should,  however,  be  made,  by  incision  and  drainage  where  practicable, 
and,  if  the  case  is  clearly  septic,  a  free  incision  at  the  site  of  the  stricture, 
or  cystotomy  in  cases  of  bladder  and  prostatic  trouble,  is  the  proper  re- 
course. 

The  management  of  chronic  urinary  toxemia  consists  in  local  antisepsis 
by  irrigation  and  prompt  removal  of  the  organic  conditions  upon  which 
the  gradual  and  constant  septic  infection  depends. 

Whenever  it  is  found  that  there  is  a  tendency  to  serious  disturbance 
after  each  operation  of  dilation  in  stricture,  whatever  type  the  morbid  phe- 
nomena may  assume,  some  more  radical  measure  must  be  substituted  for 
the  sound.  Urethrotomy  is  far  safer  than  attempts  at  dilation  in  such 
cases.     Perineal  section  and  drainage  is  often  followed  bv  no  disaa-reeable 


TREATMENT    OF    UEINAEY    EEVEE.  65 

symptoms  in  deep  stricture  in  which  every  effort  at  dilation  is  followed  by 
alarming  symptoms. 

Nervous  manifestations  attendant  upon  the  introduction  of  a  sound  and 
bearing  a  certain  relation  to  so-called  urethral  fever  are  so  frequently  seen 
that  they  are  worthy  of  special  consideration,  though  necessitating  repeti- 
tion of  points  embraced  in  the  preceding  general  discussion.  Some  indi- 
viduals of  a  nervous  temperament  are  characterized  by  extreme  hyperes- 
thesia of  the  urethral  mucous  membrane,  notably  of  its  prostatic  portion. 
The  nerves  of  sexual  sensibility  are  apparently  involved  in  the  hyperes- 
thesia, and  are  a  factor  in  the  causation  of  the  direct  and  reflex  nervous 
results  of  instrumentation.  Shivering,  a  sense  of  impending  syncope,  cold 
perspiration,  and  perhaps  nausea  are  not  infrequently  noted  during  the 
passage  of  instruments  into  the  bladder.  These  symptoms  commonly  begin 
as  soon  as  the  instrument  enters  the  membranous  urethra,  increasing  as  the 
vesical  neck  is  approached.  They  usually  pass  off  immediately,  but  may 
recur,  constituting  the  nervous  form  of  so-called  urethral  fever  already 
described. 

The  precise  cause  of  these  nervous  manifestations  is  not  clear.  They  are 
probabl}^  often  due  primarily  to  an  impressionable  nervous  system  associated 
with  timidity.  They  may,  however,  occur  in  individuals  of  strong  consti- 
tution and  undoubted  courage.  It  is  nevertheless  certain  that  fear  has 
much  to  do  with  the  causation  of  such  nervous  phenomena  in  many  in- 
stances. The  author  has  observed  that  severe  pain  and  spasm  usually  occur 
in  individuals  who  have  a  dread  of  the  treatment;  in  such  patients  consider- 
able depression  following  simple  operations  is  by  no  means  unusual. 

It  is  well  to  remember,  in  this  connection,  the  intimate  association  of 
the  nervous  supply  of  the  genito-urinary  tract — and  particularly  the  parts 
about  the  neck  of  the  bladder  and  prostate — with  the  sympathetic  ganglia. 
Eelatively-slight  disturbances  of  these  parts  produce,  in  some  individuals, 
most  profound  and  depressing  disturbance  of  the  sympathetic  nervous 
system,  as  shown  by  various  perturbations  of  the  vital  functions.  The  modus 
operandi  of  such  disturbances  is  probably  through  a  reflex  impression  made 
upon  the  sympathetic  ganglia  by  irritation  of  the  nerves  of  sexual  and 
general  sensibility  supplied  to  the  parts  involved.  Conversely,  it  will  be 
found  that  stimulation  of  this  region,  within  certain  limits,  has  a  decidedly 
stimulating  and  even  tonic  effect  upon  the  general  system.  There  are 
many  nervous  disturbances  that  are  purely  reflex,  referable  to  irritations  of 
the  sexual  apparatus  independently  of  pre-existing  inflammation.  It  is  a 
noteworthy  fact  that  inflammation  about  the  neck  of  the  bladder  and  pros- 
tate are  attended  by  more  marked  constitutional  depression  than  similar 
morbid  conditions,  of  greater  magnitude,  located  elsewhere.  This  is  only 
explicable  upon  the  theory  of  a  profound  reflex  impression  produced  upon 
the  sympathetic  via  irritation  of  the  involved  nervous  supply. 

Eelatively-pronounced  nervous  disturbance  from  slight  operations  is 


66  GEXEKAL    PHEXOMEXA    IX    GEXITO-UEIXAEY    SUECtEEY. 

also  observed  when  tissues  and  organs  correlated  to  tlie  prostate  and  vesical 
neck  are  involved.  Injuries  of  and'  operations  upon  the  testes,  anus,  and 
rectum  are  striking  examples  of  this  rule. 

Urinary  fever — and  even  minor  nervous  disturbances — rarely  occurs 
in  women,  in  Avhom  the  urethra  is  relatively  insensitive.  Aji  additional 
factor  in  their  immunity  is  the  fact  that  the  seat  of  sexual  sensibility  is  not 
located  in  this  portion  of  the  female  anatomy.  Erichsen  states  that  he  has 
only  once  seen  symptoms  of  urethral  chill  in  the  female.  This  was  in  the 
case  of  a  strong  and  healthy  young  married  lady,  who  had  a  stricture  of 
the  urethral  orifice  which  he  dilated  by  a  two-bladed  dilator.  Twenty 
hours  after  the  operation  she  had  three  most  intense  rigors,  followed  by 
profuse  sweating.^ 

It  is  obvious  that  the  danger  of  general  infection  from  urethral  dis- 
ease is  more  marked  in  the  male:  the  greater  extent  of  surface  and  more 
numerous  glands  as  compared  with  the  female  urethra  constitute  an  all- 
important  factor  in  favoring  sepsis.  The  female  urethra  is  rarely  subject 
to  lesions  that  conduce  to  general  infection.  In  cases  of  apparent  urethral 
chill  in  the  female  it  is  wise  to  look  for  coincidental  pathogenic  factors 
independent  of  the  urethral  status,  and  bearing  no  especial  relation  to  the 
operative  procedures  that  are  seemingly  responsible  for  the  rigor  or  fever. 
Hysteria  and  malaria  are  important  pathologic  possibilities  for  considera- 
tion in  this  connection.  The  author's  experience  with  urethral  chill  in  the 
female  comprises  a  single  case,  in  which  a  severe  rigor  followed  shortly  after 
cystoscopy.  A  slight  convulsion,  without  elevation  of  temperature,  suc- 
ceeded the  chill.  In  this  case  the  apparentl3^-serious  disturbance  was  prob- 
ably hysteric.  The  author  was,  to  a  certain  extent,  responsible  for  the  hys- 
teric outbreak,  having  discoursed  somewhat  didactically  before  the  patient 
on  urethral  chill  for  the  edification  of  the  assistants  during  the  operation. 

Liability  to  nervous  and  febrile  disturbances  following  instrumentation 
of  the  urethra  is  greatly  modified  by  the  location  of  the  morbid  condition 
that  is  under  treatment.  Dilation  of  stricture  in  any  part  of  the  urethra 
may  produce  such  phenomena,  but  they  are  most  frequent  after  operation 
upon  strictures  in  the  deep  portion,  not  because — as  has  been  stated  by 
some — this  part  is  most  commonly  strictured,  but  because  it  is  more  closely 
associated  with  the  nerves  of  sexual  sensibility  and  the  filaments  supplied 
by  the  sympathetic.  In  the  deep  urethra  also  we  are  most  likely  to  have 
dangerously-septic  states  of  the  mucous  membrane  and  its  environs.  Drain- 
age is  notoriously  imperfect  in  this  location;  hence  urine  is  quite  likely  to 
pocket  behind  an  obstruction.  The  same  is  true  of  pathologic  secretions. 
The  deeper  parts  of  the  urethra  being  richly  endowed  with  absorbents  as 
contrasted  with  the  penile  portion,  relatively  greater  danger  of  sepsis  is  to 
be  inferred. 


^  "Science  and  Art  of  Surgery." 


CAEE    AS    A    PKOPHYLACTIC    FACTOR.  67 

Erichsen  reports  a  case  in  wliieli  fatal  chill  followed  incision  and 
dilation  of  the  meatus.  Keflex  inhibition  of  the  function  of  the  kidneys 
produced  by  nervous  shock  was  the  probable  explanation.  Strictures  at  the 
meatus  often  produce  serious  nervous  disturbance,  reflex  spasm,  and  vesical 
troubles,  and  it  is  conceivable  that  an  operation  upon  this  sensitive  part 
might  have  a  very  profound  effect  upon  the  nervous  system  in  some  cases: 
an  effect  resulting  in  reflex  hyperemia  of  the  kidneys  with  complete  inhibi- 
tion of  their  functions  and  consequent  uremia.  This  succeeds  the  purely 
nervous  manifestations  induced  by  the  operation. 

It  is  doubtful,  however,  if  such  a  serious  result  could  occur  from  me- 
atotomy  unless  the  kidneys  were  extensively  diseased.  An  exception  might 
possibly  be  made  of  highly-neurotic  individuals  in  whom  grave  shock  may 
be  produced  by  very  trivial  operations.  Still,  death  from  pure  and  uncom- 
plicated shock  is  not  frequent  in  any  class  of  surgical  accidents  or  operations. 

It  is  to  be  remembered  that,  as  already  stated,  a  condition  of  chronic 
urinary  toxemia  underlies  many  of  the  cases  of  rigor  and  fever  following 
instrumentation  of  the  urethra.  The  nervous  system  under  such  circum- 
stances is  in  a  perpetual  state  of  irritability,  and  it  is  only  necessary  for 
some  slight  shock  to  occur  to  precipitate  a  nervous  crisis,  such  as  fatal 
convulsions.  This  shock  is  afforded  in  some  instances  by  even  the  most 
delicate  manipulations  of  the  canal. 

The  occurrence  of  the  various  symptoms  which  have  been  described 
may  be  prevented,  in  a  large  proportion  of  cases,  by  gentleness  in  manipu- 
lation, and  a  careful  study  of  the  condition  of  the  case  at  the  time  of 
each  instrumentation.  Like  other  accidents  occurring  in  the  course  of 
dilation  of  the  urethra,  much  may  be  done  in  the  way  of  prophylaxis  by 
careful  observation  of  the  exigencies  of  each  particular  case.  Eoutinism 
is  likety  to  be  attended  by  annoying  or  even  disastrous  results.  It  is  not 
at  all  surprising  that  cases  of  urethral  fever  arise  in  the  practice  of  sur- 
geons who,  regardless  of  the  effects  of  previous  instrumentations  and 
the  local  and  general  conditions  prevailing  at  the  time  of  operation,  dilate 
all  cases  of  stricture  in  a  routine  fashion  every  second  or  third  day.  The 
condition  of  the  stricture  itself  as  regards  irritability  has  much  to  do  with 
the  development  of  nervous  manifestations  after  dilation.  Given  a  highly- 
irritable  state  of  the  contracted  tissue,  a  primarily-susceptible  nervous 
organization,  and  chronic  uremia,  in  combination  with  unskillful  attempts 
at  instrumentation,  urethral  chill — and  perhaps  fever — is  almost  inevitable. 

The  administration  of  anodynes;  the  preliminary  use  of  hot  baths, 
diaphoretics,  and  other  derivative  and  eliminative  measures  of  treatment; 
with  the  careful  application  of  cocain  in  mild  solution  and  moderate  quan- 
tity at  the  time  of  the  operation,  are  very  useful  in  the  prevention  of  dis- 
agreeable nervous  results. 

The  remedies  that  are  generally  recognized  as  valuable  in  the  pre- 
vention of  urethral  chill  have  already  been  mentioned.     It  is  noteworthy 


68  GENEEAL    PHENOMENA   IN    GENITO-UEINAET    SUEGEEY. 

that  they  are  all  remedies  which  act  selectively,  so  to  speak,  upon  the 
nervous  mechanism. 

Where  the  operation  of  dilation  produces  severe  shock,  it  may  be 
necessary  to  administer  hot  toddy  or  some  other  form  of  stimulant.  Wine 
of  coca  is  beneficial  to  patients  of  a  very  impressionable  nervous  tempera- 
ment. 

Eegarding  the  possibility  of  nervous  manifestations  from  dilation,  the 
surgeon  should  never  introduce  instruments  with  the  patient  in  the  stand- 
ing posture  until  tolerance  on  the  part  of  the  nervous  system  has  been  ac- 
quired. It  is  a  very  unpleasant  thing  to  have  a  patient  fall  upon  the  floor 
in  a  dead  faint  while  an  instrument  is  being  introduced:  an  accident  that 
occasionally  happens.  Extreme  sensibility  of  the  urethra,  and  incidently 
of  the  nervous  system,  are  often  observed  where  the  urethra  has  not  been 
previously  explored.  This  local  and  general  hyperesthesia  soon  becomes 
blunted,  as  a  rule,  by  the  local  and  constitutional  effects  of  instrumentation. 
It  will  be  found,  after  a  few  seances,  that  operations  are  well  tolerated.  In 
some  exceptional  cases,  however,  the  urethra  remains  permanently  intoler- 
ant of  instruments,  and,  no  matter  how  long  the  treatment  may  be  con- 
tinued, severe  spasm,  nervous  shock,  and  perhaps  rigors  will  be  produced 
hy  instrumentation. 


PART  11. 

NON- VENEREAL  DISEASES  OF  THE  PENIS. 


CHAPTER  VI. 

Anatomy  and  Physiology,  Anomalous  Formations,  Traumatisms, 
Acute  and  Chronic  Inflammations,  Neoplasms,  and  Amputation 
OP  THE  Penis. 

The  first  subject  that  demands  consideration  in  the  special  study  of  the 
diseases  of  the  male  genito-urinary  organs  is  naturally  the  various  patho- 
logic conditions  affecting  the  organ  of  generation. 

Anatomy  and  Physiology  op  the  Penis.  —  The  penis  is  designed 
chiefly  for  the  performance  of  the  reproductive  function.  The  urine  is  as 
readily  expelled  after  removal  of  the  penis  as  when  the  organ  is  intact.  In 
the  average  perfectly-formed  adult  the  quiescent  penis  measures  from  2  to 
4  ^/a  inches  in  length,  this  measurement  varying  with  emotional  excitement 
and  increasing  imder  sexual  stimulus  to  from  5  to  7  inches.    The  size  of  the 


Fig.  6. — Section  of  the  penis  at  about  its  middle.     (After  Cruveilhier.) 

flaccid  organ  is  no  criterion  of  its  dimensions  when  ready  for  the  act  of 
copulation,  the  organ  in  some  instances  being  disproportionately  large  when 
erect.  On  the  other  hand,  a  comparatively  large  penis  may  increase  very 
little  in  size  during  erection. 

The  organ  may  be  divided  into  three  portions:  The  base,  or  root;  the 
body;  and  the  anterior  expanded  extremity,  or  glans.  The  base  of  the 
penis  is  closely  attached  to  the  pubic  rami  by  two  strong  fibrous  processes 
known  as  the  crura;  it  is  attached  to  the  front  of  the  pubic  symphysis 
by  a  fibrous  membrane,  the  suspensory  ligament  of  the  penis.  The  body 
is  composed  of  three  portions:  two  above,  the  corpora  cavernosa,  and  one 
below,  the  corpus  spongiosum.  The  latter  contains  the  urethra.  These  three 
bodies  are  bound  together  by  a  firm  fascia  to  be  subsequently  described 
(Buck's  fascia),  each  body  having  also  a  special  fibrous  envelope. 

(69) 


70  KOX-TEXEEEAL    DISEASES    OF    THE    PENIS. 

The  corpora  cavernosa  form  the  major  part  of  the  erectile  tissues  of  the 
penis;  they  are  situated  side  by  side  and  united  by  fibrous  tissue.  Tliey 
resemble  two  cylindrical  tubes,  the  septum  between  which  is  imperfect 
and  permits  the  passage  of  blood  from  one  to  the  other.  The  interior  of 
each  is  trabeculated^  the  spaces  thus  formed  being  continually  filled  with 
blood.  I'pon  the  walls  of  these  spaces  ramify  the  small  arteries  that  con- 
stitute the  most  important  part  of  the  erectile  tissue.  These  arteries  are 
curled  peculiarly^  being  termed,  from  their  resemblance  to  a  helix  or  coil, 
the  helicine  arteries.  The  septum  between  the  two  bodies  is  termed  the 
septum  pectmiforme,  from  its  resemblance  to  the  teeth  of  a  comb.  The 
fibrous  investment  of  the  corpora  cavernosa  is  so  dense  and  strong  that  it 
is  capable  of  supporting  the  weight  of  the  entire  body.  The  free  com- 
munication between  the  interior  of  the  cavernous  bodies  permits  equable 
enlargement  of  the  jDenis  under  sexual  excitement. 

Erection  is  said  by  most  authorities  to  be  due  to  practically  passive 
congestion  produced  by  compression  of  the  dorsal  vein  of  the  penis  by  a 
special  muscle — the  erector  penis — with  consequent  venous  obstruction  and 
distension.  This,  however,  is  not  a  sufficient  explanation,  else  it  would  be 
practicable  to  produce  a  vigorous  erection  by  constricting  the  root  of  the 
organ.  Erection  is  due  to  active  reflex  hyperemia  produced  by  dilation  of 
the  tortuous  helicine  arteries  under  the  stimulus  of  sexual  excitement.  The 
phenomena  of  erection  are,  in  many  respects,  analogous  to  the  hyperemia 
of  the  skin  produced  by  psychic  impressions  popularly  known  as  blushing. 
The  vascular  phenomena  in  both  are  produced  by  a  reflex  impression  upon 
the  vasomotor  filaments  of  the  sympathetic.  The  venous  congestion  accom- 
panying erection  results  from  obstruction  produced  by  the  pressure  of  the 
distended  arterioles. 

The  corpora  cavernosa  begin  posteriorly  just  in  front  of  the  ischial 
tuberosities,  passing  upward  and  forward  upon  either  side  and  joining  in 
the  median  line.  Xear  their  junction  each  cavernous  body  presents  a 
slight  enlargement:  the  hulb  of  the  corpus  cavernosum.  The  corpora  caver- 
nosa terminates  anteriorly  in  a  conic  extremity  adapted  to  a  concavity  upon 
the  posterior  surface  of  the  glans. 

The  corpus  spongiosum  contains  the  urethra,  and  is  situated  in  the 
median  line  beneath  the  corpora  cavernosa.  It  commences  posteriorly,  just 
in  front  of  the  deep  fascia  of  the  perineum,  in  a  rounded  bulb,  the  iulb  of 
the  corpus  spongiosum,  and  terminates  anteriorly  in  another  expansion, 
the  glan^  penis.  The  posterior  surface  of  the  glans  is  concave,  fitting 
accurately  the  conic  extremity  of  the  corpora  cavernosa,  there  being, 
however,  no  vascular  connection.  The  glans  is  conic  in  shape,  somewhat 
flattened  above;  at  its  anterior  extremity  is  the  meatus  urinarius.  The 
base  of  the  glans  presents  a  circular  projecting  border,  the  corona  glandis, 
behind  which  is  a  furrow,  the  fossa  glandis.  Upon  the  corona  and  in  the 
fossa  are  found  a  considerable  number  of  sebaceous  Eclands.  the  glands  of 


ANATOMY    OF    THE    PEXIS.  71 

Tyson,  or  glandulce  odoriferce.  These  secrete  a  sebaceous  matter,  the 
smegma  preputii,  which  is  of  highly-nitrogenized  composition  and  readily 
decomposes,  developing  a  very  offensive  and  characteristic  odor. 

The  function  of  the  glans  penis  is  probably  to  afford  a  soft  and  deli- 
cate expansion  for  the  exquisitely  sensitive  filaments  of  the  nerves  of  sexual 
sensibility. 

The  arteries  of  the  penis  are  derived  from  the  internal  pudic.  Each 
corpus  cavernosum  has  a  separate  artery,  the  artery  of  the  corpus  caver- 
nosum,  and  also  small  branches  from  the  dorsal  artery  of  the  penis. 
Special  arteries — the  arteries  of  the  bulb — supplied  by  the  internal  pudic 
to  the  corpus  spongiosum,  are  very  important  in  their  surgical  relations. 

The  lymphatics  of  the  penis  consist  of  two  sets:  superficial  and  deep. 
The  superficial  terminate  in  the  inguinal,  the  deep  in  the  pelvic  glands. 

The  nerves  of  the  penis  are  branches  of  the  internal  pudic  nerve  and 
hypogastric  plexus.  Upon  the  glans  a  few  Pacinian  bodies  are  found  in 
connection  with  the  nervous  filaments. 

The  hulh  of  the  corpus  spongiosum  is  a  factor  in  the  expulsion  of  the 
final  drops  of  urine  in  micturition  and  of  semen  in  copulation.  It  is 
surrounded  by  comparatively-strong  muscular  fibers.  The  prostate,  levator 
ani,  and  deep  urethral  muscles  force  the  fluid  into  the  bulbous  urethra;  the 
accelerator-urince  muscle  then  impels  the  fluid  by  a  peculiar  undulatory 
motion  forward  to  the  meatus.  When  this  action  of  the  accelerator  is  in- 
hibited, as  is  often  the  case  in  organic  stricture,  the  final  drops  of  urine  are 
retained,  subsequently  dribbling  away  and  soiling  the  patient's  clothing. 
Sterility  may  be  thus  caused,  extrusion  of  semen  being  incomplete. 

The  three  bodies  comprising  the  penis  are  bound  firmly  together  by  a 
proper  fibrous  sheath.  This  is  a  very  important  structure  in  its  surgical 
relations.     It  was  first  accurately  described  by  Gurdon  Buck. 

Buch's  fascia  is  really  the  deep  layer  of  the  superficial  fascia  of  the 
perineum  which,  curving  under  the  transversus  perinei  muscles,  becomes 
blended  with  the  anterior  layer  of  the  triangular  ligament.  In  this  con- 
nection it  should  be  borne  in  mind  that  the  so-called  special  fascias  are 
really  not  separate  and  distinct  entities.  They  consist  of  areas  of  the  gen- 
eral fascia  of  the  body,  which,  by  virtue  of  certain  physiologic  relations 
with  the  parts  they  invest,  or  because  of  their  surgical  relations  to  various 
pathologic  conditions,  have  seemed  to  merit  special  description.  Thus,  the 
intercolumnar  fascia  is  simply  the  deep  layer  of  the  superficial  fascia  which 
assumes  an  important  position  because  it  covers  the  external  inguinal  ring 
and  is  attached  to  its  pillars  or  columns.  The  cribriform  fascia  is  merely 
a  part  of  the  deep  layer  of  the  general  fascia  of  the  thigh,  investing  the 
saphenous  opening  and  perforated  by  the  saphenous  vein. 

Buck's  fascia  rises  from  the  linea  alba  and  pubic  symphysis,  where  it  is 
continuous  with  a  triangular  fibrous  structure  known  as  the  suspensory  liga- 
ment of  the  penis.    It  spreads  out  laterally  upon  the  corpora  cavernosa  and 


72 


NON-VENEREAL    DISEASES    OF    THE    PENIS. 


extends  forward  over  their  conic  extremity,  becoming  attached  to  the 
under  surface  of  the  glans.  After  encircling  the  corpora  cavernosa  Bnck's 
fascia  splits  into  two  layers  that  inclose  the  corpus  spongiosum.  It  is 
attached  laterally  to  the  rami  of  the  pubes.  This  peculiar  arrangement 
prevents  burrowing  of  infiltrated  urine  or  pus,  so  long  as  the  fascia  is  intact, 
excepting  in  one  direction,- — above, — where,  as  shown  by  Eichet,  it  is 
blended  with  the  general  abdominal  fascia.  A  large  collection  of  fluid  is, 
therefore,  likely  to  burrow  upward  into  the  subcutaneous  tissue  of  the  abdo- 
men, passing  outward  along  Poupart's  ligainent  into  the  groin.  The  fascia 
rarely  yields  laterally,  permitting  infiltration  of  fluid  into  the  cellular  tissue 
of  the  thighs. 


Fig.  7. — Buck's  fascia.     (After  Gurdon  Buck.) 


Tlie  integument  of  the  penis  resembles,  in  general,  that  of  the  rest  of 
the  body.  It  has,  however,  a  peculiar  tendency  to  pigmentation,  and  is  very 
loose,  there  being  little  areolar  tissue  beneath  it.  It  is  attached  firmly  to 
the  neck  of  the  glans,  being  folded  over  that  structure  to  form  the  prepuce. 
The  prepuce  is  necessarily  composed  of  two  layers:  internal  and  external. 
The  internal  layer,  being  protected  and  moist,  forms  a  quasimucous  mem- 
brane. On  the  under  surface  of  the  prepuce  is  a  small,  cord-like  structure 
that  attaches  the  internal  layer  to  the  under  surface  of  the  glans;  this  is 
termed  the  frenum  preputii,  and  contains  a  small  artery,  which,  if  cut  or 
eroded  by  ulceration,  sometimes  gives  rise  to  considerable  hemorrhage. 


TEAUMATISMS    OF    THE    PENIS.  73 

Anomalous  Foemations  of  the  Penis. — Congenital  anomalies  of  the 
penis  are  rare  and  seldom  demand  surgical  interference. 

Variations  in  the  dimensions  of  the  organ  are  of  no  surgical  importance. 
Double  penis  has  been  observed,  but  is  so  rare  that  it  is  a  curiosity.  Van 
Buren  mentions  a  single  case  coming  under  his  observation  in  which  two 
distinct  male  organs  of  normal  size  and  apparently  perfect  formation  were 
situated  side  by  side,  each  being  attached  at  its  base  to  the  symphysis  pubis. 
One  of  the  organs,  the  right,  was  the  larger.  There  was  either  a  double 
urethra  or  a  diverticulum  from  the  urethra  that  opened  in  the  perineum 
behind  the  scrotum.  The  meatus  in  the  left  organ  was  impervious.  Sexual 
desire,  erection,  and  emission  were  apparently  normal.  The  individual  was 
effeminate,  as  is  likely  to  be  the  case  in  congenital  malformations  of  the 
male  sexual  organs. 

Double  penis  corresponds  to  the  uterus  bicornis  and  double  vagina 
occasionally  seen  in  the  female.  Cases  have  been  recorded  of  congenital 
absence  of  the  penis,  the  scrotum  and  testes  being  perfectly  developed  and 
the  urethra  represented  by  a  rectal  opening.  This  arrangement  is  similar 
to  that  which  exists  normally  in  birds.  Van  Buren  and  Keyes,^  quoting 
from  Nelaton  and  Groschler,  admit  the  existence  of  such  cases.  More  recent 
writers  have  also  reported  cases  of  the  kind. 

Injuries  of  the  Penis. — Traumatism  of  the  penis  is  relatively  infre- 
quent, it  being  quite  difficult  to  injure  the  organ  accidentally.  Eupture  of 
the  cavernous  bodies,  more  often  of  the  corpus  spongiosum,  has  been  seen. 
Violent  attempts  at  coitus,  especially  in  the  presence  of  chordee,  may  pro- 
duce it.  A  few  cases  of  fracture  of  the  penis  produced  in  this  manner  have 
been  reported.  Bruises  of  the  penis  are  liable  to  give  rise  to  considerable 
ecchymosis,  sometimes  to  extensive  extravasation  of  blood,  because  of  the 
relatively  large  size  of  the  blood-vessels,  notably  the  veins,  and  the  extreme 
looseness  of  the  areolar  tissue,  which  offers  little  resistance  to  the  diffusion 
of  fluid. 

Wounds  of  the  penis  are  sometimes  produced  by  self-mutilation.  The 
insane,  especially  those  suffering  from  masturbatory  melancholia,  not  in- 
frequently deliberately  injure  their  sexual  organs.  Female  jealousy  is 
occasionally  responsible  for  wounds  of  the  penis.  The  author  recalls  two 
cases  of  wounds  inflicted  by  women.  In  one  case  the  woman  claimed  to 
have  been  defending  herself  from  an  attempted  outrage.  In  the  other  case 
a  man  suffered  complete  amputation  of  the  penis  by  his  jealous  wife. 
Another  instance  of  injury  of  the  penis  that  came  under  the  author's  obser- 
vation was  peculiar.  A  boatman  was  set  upon  while  in  the  act  of  urinating 
behind  a  building  by  a  huge  dog  and  suffered  considerable  mutilation  of 
the  penis. 

The  dangers  of  injury  to  the  penis  are  hemorrhage,  inflammation,  ab- 


^  "Surgical  Diseases  of  the  Genito-Urinary  Organs.' 


74  NON-YENEEEAL    DISEASES    OF    THE    PENIS. 

scess,  septic  infection  from  decomposition  of  extravasated  bloody  urinary 
infiltration,  gangrene,  fistula,  and  subsequent  deformity  of  the  organ. 

Tkeatment. — Contusions  of  the  organ  warrant  little  interference. 
Complete  rest,  with  either  the  cold-water  coil  or  ice-bags  to  limit  extravasa- 
tion and  inflammation,  is  essential.  Incision  of  the  contused  tissues  should 
be  avoided,  else  infection,  with  resultant  extensive  suppuration  and  perhaps 
septic  processes,  may  ensue.  In  some  cases  the  penis  may,  with  advantage, 
be  encircled  by  adhesive  straps  to  prevent  further  extravasation  and  promote 
absorption  of  the  effused  blood.  Clean  cuts  upon  the  surface  of  the  organ 
should  be  sutured  with  fine  catgut,  horsehair,  or  silk  sutures,  after  which 
the  cold-water  coil  should  be  applied.  Cold  is  necessary  to  prevent  reopen- 
ing of  the  wound  during  erection,  with  consequent  hemorrhage  and  slow 
healing.  The  extreme  heat  of  the  sexual  organs,  and  the  reflex  tendency 
to  erection  incidental  to  irritations  about  the  penis,  are  among  the  principal 
obstacles  to  be  overcome  in  the  surgery  of  the  part. 

When  there  is  inflltration  of  urine  free  antiseptic  incision  is  an  urgent 
necessity.  In  cases  of  fracture  of  the  corpora  cavernosa  the  passage  of  a 
gum  catheter  of  moderate  size  into  the  bladder  has  been  recommended. 
The  instrument  should  be  anchored  and  the  penis  compressed  upon  it  with 
adhesive  straps,  the  cold  coil  being  applied  over  all.  If  extravasation  of 
blood  is  so  extensive  that  gangrene  seems  imminent,  tension  should  be 
relieved  by  aseptic  aspiration  or  puncture.  Cases  have  been  recorded  in 
which  gangrene  following  injury  necessitated  amputation  of  the  organ. 

Diseases  of  the  Body  of  the  Penis. — Simple  acute  inflammation  of 
the  corpora  cavernosa  is  but  rarely  seen;  it  may,  however,  result  from  in- 
juries. 

Chronic  inflammation  is  also  rare;  and  its  causes  are  very  obscure.  In 
some  few  recorded  instances  it  has  been  attributed  to  syphilis.  It  is  readily 
conceivable  that  a  syphilitic  deposit  may  occur  either  in  the  erectile  tissue 
or  fibrous  envelope  of  the  cavernous  bodies.  This  may  excite  proliferation 
of  connective  tissue,  producing  thickening  of  the  corpora  cavernosa.  As  a 
consequence,  impairment  of  elasticity  results  and  erection  is  apt  to  be  de- 
fective. This  condition  appeared  in  one  of  the  author's  cases  several  weeks 
after  operation  for  stricture  by  a  competent  surgeon.  There  was  a  perma- 
nent lateral  deviation  of  the  organ  during  erections.  This  patient,  how- 
ever, was  suffering  from  late  secondary  syphilis,  and  it  would  be  difficult  to 
determine  what  influence  the  constitutional  disease  had  over  the  morbid 
condition  following  urethrotomy.  In  some  instances  calcific  material  is  de- 
posited at  the  seat  of  the  chronic  inflammation,  giving  rise  to  a  peculiar 
condition  that  has  been  erroneously  termed  ossiflcation  of  the  penis.  In 
other  instances  the  fibrous  deposit  becomes  pseudocartilaginous.  The  plates 
of  cartilaginous  or  calcific  material  may  be  readily  felt  through  the  superly- 
ing  tissues.  In  some  instances  they  are  localized  and  of  small  dimensions,  in 
others  encircling  the  greater  portion  of  the  circumference  of  the  corpora 


CAVERNOSITIS.  75 

cavernosa.  It  has  been  asserted  that  deposits  resulting  from  chronic  cav- 
ernous inflammation  are  apt  to  move  from  the  original  location,  in  some 
instances  gradually  advancing  to  the  root  of  the  penis.  The  author's  experi- 
ence has  apparently  confirmed  this. 

Gout  seems  to  bear  a  very  important  etiologic  relation  to  chronic 
cavernositis.  What  relation  long-forgotten  traumatism  may  bear  to  it  is 
an  open  question.  We  must  not  overlook  the  possible  analogy  of  stricture's 
following  old-time  trauma  and  urethritis. 

The  author  has  met  with  two  cases  in  which  inflammation  of  the 
corpora  cavernosa  developed  as  a  complication  of  chronic  urethritis  and 
stricture.  In  one  case  there  was  marked  lateral  deviation  of  the  penis  during 
erection;    several  plaques  of  induration  were  discernible.     Eecovery  ensued 


Fig.  8. — "Osseous"  degeneration  of  the  penis.     (After  Demarquay.) 

after  some  months  of  urethral  treatment  conjoined  with  the  faradic  current 
and  massage. 

The  conditions  described  are  of  importance  only  as  regards  their  psychic 
results  and  possible  interference  with  erection. 

Keyes  has  recorded  several  interesting  cases  of  chronic  circumscribed 
inflammation  of  the  erectile  tissue  of  the  corpora  cavernosa.  The  author's 
personal  experience  comprises  four  uncomplicated  cases. 

The  treatment  of  cavernositis  offers  very  little  hope  of  success  in  most 
instances.  The  only  cases  susceptible  to  remedial  measures  are  those  of 
unequivocal  syphilitic  deposit  prior  to  fibroconnective-tissue  deposit  and 
those  dependent  upon  chronic  urethritis. 

In  three  of  the  author's  typic  cases  no  improvement  resulted  from 
treatment.  In  one,  however,  in  which  there  was  a  history  of  possible  syph- 
ilis, large  and  increasing  doses  of  iodide  of  potassium,  with  local  inunctions 


76  iN'OX-YENEKEAL    DISEASES    OF    THE    PEXIS. 

of  mercury^  reduced  the  induration  to  a  considerable  extent^  but  did  not 
remove  it  entirely.  Antilitliic  remedies  are  always  in  order  in  view  of  a 
possible  gouty  origin. 

Counter-irritation  seems  to  be  of  little  or  no  service.  Electricity  may 
possibly  afford  some  benefit,  although,  its  use  in  this  affection  has  not  been 
satisfactory  thus  far.    Electrolysis  is  worse  than  useless. 

Inflammaiion  of  the  corpus  spongiosum  is  by  no  means  rare,  but  it 
occurs  chiefly  as  a  complication  of  gonorrhea  and  stricture,  and  will  be 
described  in  connection  with  those  affections.  Chordee,  as  will  be  seen 
later,  is  an  example  of  acute  inflammation  affecting  the  spongy  body  of 
the  penis,  and  in  certain  exceptional  instances  chronic  chordee  illustrates 
the  effects  of  chronic  inflammation  of  this  structure. 


Fig.  9. — Penile  epithelioma.    Vegetating  form.     (After  White  and  Martin.) 

Xew  Growths  of  the  Pexis. — Tumors  of  various  kinds  occur  upon 
the  penis;  nearly  all  the  simpler  varieties  of  tumor  may  be  met  with.  They 
are,  however,  relatively  rare,  malignant  growths  being,  perhaps,  more  fre- 
quent. Tumors  of  a  cystic,  fibroid,  lipomatous,  telangiectatic,  or  nevoid 
character  have  been  observed. 

Cancer  of  the  penis  usually  occurs  in  the  form  of  epithelioma,  other 
varieties  being  exceedingly  rare.  Sarcoma  has  been  noted  in  young  subjects 
as  a  more  or  less  remote  result  of  trauma.  This  form  of  malignant  growth 
develops  very  rapidlj^,  speedily  infects  the  neighboring  glands  and  soon 
produces  death  by  exhaustion,  with  or  Avithout  general  dissemination. 

Epithelioma  may  invade  either  the  mucous  membrane  of  the  glans  or 
the  integument  of  the  orsfan..    It  affects  men  above  middle  age.  as  a  rule. 


EPITHELIOMA    OF    THE    PEXIS.  77 

The  author,  however,  has  met  with  a  case  in  a  young  man,  28  years  of  age, 
in  whom  epithelioma  developed  on  the  site  of  an  indurated  chancre  and  after 
several  operations  eventually  resulted  fatally.  The  diagnosis  in  this  case 
was  verified  by  the  microscope.  The  disease  is  often  mistaken  in  its  in- 
cipiency  for  a  late  syphilitic  lesion.  The  speedy  involvement  of  the  inguinal 
and  femoral  glands  and  the  use  of  the  microscope  readily  makes  the  diag- 
nosis clear.  Early  syphilis  is  not  likely  to  lead  to  diagnostic  errors.  The 
disease  runs  a  course  similar  to  that  of  epithelioma  elsewhere,  the  average 
duration  of  the  disease  being  from  one  to  two  years.  Death  finally  results 
from  exhaustion  and  general  disturbance  of  nutrition.  In  some  cases  the 
disease  attacks  secondarily  the  testicle  and  spermatic  cord;  in  rare  instances 
the  prostate  and  bladder  are  involved.  A  case  of  this  kind  has  occurred 
in  the  author's  experience: — • 

Case. — The  patient  was  a  man  about  45  years  of  age,  epithelioma  of  the  glans 
penis  having  existed  for  some  months.  The  disease  had  progressed  very  rapidly,  and 
at  the  time  of  examination  the  tumor  was  the  size  of  a  small  orange  Amputation  of 
the  penis  was  advised  and  consented  to.  The  growth  soon  recurred  after  operation 
and  speedily  involved  the  greater  part  of  the  scrotum  and  the  perineal  portion  of  the 
urethra.  By  the  time  the  patient  consented  to  a  second  operation  the  disease  had 
extended  along  the  spermatic  cord  and  invaded  the  inguinal  canal.  Micturition  had 
become  very  difficult,  and  it  was  impossible  to  pass  an  instrument  into  the  bladder 
without  producing  free  bleeding.  Urination  after  instrumentation  was  attended  hj 
the  discharge  of  portions  of  what  was  evidently  a  secondary  growth  in  and  about  the 
prostate  and  vesical  neck,  evidence  of  which  was  afforded  by  digital  examination  per 
rectum.  The  obstruction  to  micturition  continuing,  the  patient  submitted  to  an 
operation  for  the  removal  of  so  much  of  the  disease  as  might  be  necessary  for  the 
purpose  of  freeing  the  urethra  from  obstruction,  it  being  evidently  impracticable  to 
entirely  remove  the  growth.  It  was  found  necessary  to  excise  the  perineal  portion  of 
the  penis  as  low  down  as  the  junction  of  the  crura.  As  much  healthy  urethra  as 
possible  was  preserved.  This  was  everted  and  stitched  to  the  margins  of  the  wound. 
The  tunica  vaginalis  was  found  to  be  involved  in  the  growth  and  a  portion  of  it  was 
dissected  away  with  the  scrotum,  the  dissection  being  carried  upward  into  the  inguinal 
canal  for  some  distance.  The  patient  soon  recovered  from  the  operation,  although  the 
kidneys,  as  shown  by  the  condition  of  the  urine,  were  evidently  markedly  diseased. 
Death  occurred  from  uremia  some  eight  weeks  later,  the  wound  having  healed  and 
urination  having  been  comparatively  free  since  the  operation.  At  the  autopsy  the 
bladder  and  prostate  were  found  to  be  extensively  involved.  The  kidneys  were  the 
seat  of  chronic  parenchymatous  inflammation. 

Epithelioma  of  the  penis  usually  develops  upon  the  mucous  membrane 
as  a  small  ulceration  or  excoriation  that  subsequently  becomes  indurated 
and  slowly  invades  the  surrounding  tissues.  It  may  appear  in  the  form  of 
a  small  scaly  patch  which,  when  removed,  reveals  at  first  an  excoriated,  and 
later  on  an  ulcerated,  surface.  The  lesion  soon  begins  discharging  a  thin, 
foul,  unhealthy-looking  ichor,  or  sanies;  the  ulceration  spreads  and  deepens, 
becoming  irregular,  with  purplish  and  ragged  edges.  Later  on  the  ulcera- 
tion becomes  very  rapid  and  destructive.  In  some  instances  the  point  of 
departure  is  a  warty  excrescence;  this  soon  comes  away,  revealing  an  ulcer 


78  NON-VENEKEAL    DISEASES    OF    THE    PENIS. 

beneath.  The  disease  may  invade  surrounding  parts  very  rapidly,  finally 
opening  some  large  blood-vessel  or  a  succession  of  small  vessels,  the  hemor- 
rhage from  which  hastens  a  fatal  issue. 

Clinical  observation  shows  that  all  chronic  ulcerative  lesions,  warty 
or  scaly  growths  upon  the  penis  in  men  above  or  about  middle  age  are 
open  to  suspicion  and  should  be  carefully  watched  and  microscopically 
studied,  particularly  if  there  be  a  history  of  syphilis  or  recent  venereal  in- 
fection or  if  the  lesion  fails  to  yield  to  antisyphilitic  remedies  in  cases  of 
suspected  syphilis.  Such  conscientious  observation  is  the  only  safeguard  for 
the  patient,  whose  sole  reliance  is  an  early  and  radical  operation  should 
cancer  be  proved  to  exist.  Cancer  of  the  penis  may  begin  primarily  in  the 
urethra,  this,  however,  being  very  rare.^ 

Tebatment. — The  treatment  of  tumors  of  the  penis  of  whatever  kind 
consists  in  excision  where  possible,  with  due  regard  for  the  genital  function 
of  the  organ  and  the  possibility  of  avoiding  an  operation  that  will  necessarily 
cripple  the  part.  Cancerous  growths,  unfortunately,  are  rarely  brought  to 
our  attention  until  so  far  developed  that  amputation  is  the  only  recourse, 
though  it  is  questionable  whether  a  less  radical  operation  is  ever  warrant- 
able, even  when  an  early  diagnosis  is  made. 

Amputation  of  the  penis  is  a  comparatively-simple  operation.  It  has 
fr'equently  been  performed  by  means  of  the  ecraseur  and  galvanoeautery 
according  to  the  old-time  methods  of  Maisonneuve  and  Chassaignac.  The 
knife,  however,  is  always  to  be  preferred  to  such  methods,  as  being  more 
cleanly  and  surgical  and  more  thoroughly  under  the  control  of  the  operator. 
Dangerous  hemorrhage,  inflammation,  and  sloughing  may  follow  the 
ecraseur  or  cautery  operation. 

In  very  early  amputation  of  the  penis  as  much  of  the  organ  should  be 
saved  as  is  consistent  with  the  entire  removal  of  the  disease.  To  prevent 
the  organ  from  shrinking  back  under  the  arch  of  the  pubis  in  amputation 
near  its  root,  thus  preventing  the  surgeon  from  grasping  the  blood-vessels, 
the  part  should  be  transfixed  through  the  corpora  cavernosa  with  a  stout 
ligature  and  excised  anteriorly  to  it.  The  corpora  cavernosa  should  be  di- 
vided first.  The  urethra  should  be  left  a  little  longer  than  the  body  of  the 
organ,  according  to  the  method  of  Teale.  This  consists  in  splitting  the  ure- 
thra upon  its  under  surface,  turning  the  resulting  rectangular  flap  up  over 
the  face  of  the  stump  and  stitching  the  edges  of  the  mucous  membrane  to 
the  edges  of  the  integument.  The  patency  of  the  urethra  is  thus  secured 
and  otherwise  inevitable  stricture  avoided.  There  is  usually  considerable 
hemorrhage,  and,  as  a  rule,  four  or  five  vessels  demand  ligature,  the  vessels 
of  the  corpora  cavernosa  and  corpus  spongiosum  being  ligated  separately. 
Antiseptic    dressings    and    a    retained    catheter    complete    the    operation. 


^  Van  Hook  has  reported  two  cases  of  this  kind :    Chicago  Medical  Kecorder,  No- 
vember, 1897. 


AMPUTATION    OF    THE    PENIS.  79 

Should  oozing  of  blood  be  persistent,  styptics,  hot  water,  or  the  actual 
cautery  may  be  required.  The  retained  catheter  may  be  dispensed  with,  the 
urine  being  drawn  with  a  soft  catheter  at  regular  intervals.  Whenever  the 
disease  is  fairly  well  advanced  the  entire  organ  should  be  removed,  with  the 
testes  if  necessary,  and  a  perineal  fistula  made.  All  infected  glands  should 
be  thoroughly  removed. 

When  cancer  of  the  penis  involving  the  deep  urethra  and  prostate  is 
inoperable,  suprapubic  cystotomy  and  drainage  may  become  necessary  to 
relieve  pain  and  urinary  obstruction.  When  the  growth  involves  the 
perineal  urethra  yet  is  operable,  an  artificial  urethra  opening  in  the 
perineum  may  be  easily  made  where  it  is  possible  to  preserve  a  small  portion 
of  the  proximal  end  of  the  normal  urethra.  Otherwise  a  permanent  supra- 
pubic fistula  is  required. 


CHAPTEE  YII. 

Diseases  of  the  Skix  axd  QuASi:Mircous  Membeaxe  of 
THE  Penis. 

A  NUMBER  of  pathologic  conditions  of  the  penis  are  entirely  super- 
ficial and  integumentary  in  character,  involving  only  the  skin  or  quasi- 
mucous  membrane.  The  most  important  of  these  are:  1.  Deformities  of  the 
prepuce,  congenital  or  acquired,  comprising  redundancy,  phimosis,  and 
paraphimosis.  2.  Inflammation  of  the  prepuce  and  quasimucous  covering 
of  the  gians,  balanitis,  and  posthitis  or  balanoposthitis.  3.  Simple  acne  of 
the  penile  integument.  4.  Eczema,  acute  or  chronic.  5.  Herpes  progeni- 
talis.  6.  Simple  ulcer.  7.  Lymphangitis  (erysipelatous  or  venereal).  8. 
Phlegmonous  erysipelas.  9.  Venereal  vegetations  or  simple  papillomata. 
10.  Chancre  and  chancroid.  11.  Various  forms  of  syphilide.  12.  Lupus 
erythematosus.     13.  Psoriasis. 

Phimosis  implies  a  constriction  of  the  preputial  orifice  that  prevents 
retraction  of  the  prepuce  and  exposure  of  the  glans.  It  may  result  from 
thickening  produced  by  balanoposthitis,  chancre,  or  chancroid.  Chancroid 
is  especially  likely  to  cause  chronic  thickening  of  the  prepuce,  the  tissues 
of  which  become  of  a  cartilaginous  consistency.  A  large  proportion  of 
children  are  affected  with  congenital  phimosis:  a  certain  number  finally 
succeed  in  uncovering  the  glans,  but  many  find  it  impossible  to  do  so  with- 
out surgical  interference.  Phimosis  in  young  children  may  produce  results 
worthy  of  serious  consideration.  It  has  been  proved  beyond  dispute  that 
phimosis  is  capable  of  producing  serious  reflex  nervous  disturbance.  Thus, 
convulsive  affections,  such  as  epilepsy,  chorea,  and  various  forms  of  paralysis 
(most  frequently  paraplegia)  have  been  produced  by  the  reflex  irritation  of 
a  phimosed  prepuce.  The  author  has  seen  glycosuria  cured  by  circumcision 
of  a  phimosed  prepuce.^  It  being  impossible  to  uncover  the  glans  in  phi- 
mosis, the  smegma  preputii  accumulates  under  the  prepuce  behind  the 
corona  giandis  and  forms  a  hard  ring  about  the  organ  that  produces  intense 
irritation.  This  irritation,  being  reflected  to  the  spinal  cord,  produces  seri- 
ous disturbance.    Balanitis  is  also  excited,  and  in  some  instances  pus  forms. 

An  evil  that  frequently  results  is  masturbation.  The  irritation  be- 
neath the  prepuce  induces  the  child  to  pull  at  the  penis  in  the  attempt 
to  obtain  relief.  Pleasurable  sensations  having  once  been  experienced,  the 
child  is  likely  to  become  a  confirmed  masturbator. 

Paraphimosis  consists. of  the  imprisonment  of  the  prepuce  behind 
the  corona  giandis.  This  is  very  apt  to  occur  in  young  children,  who, 
after  retracting  the  prepuce,  are  unable  to  again  draw  it  forward.    It  also 


^  Tide  chapter  on  "Urinalysis  in  its  Surgical  Relations.' 
(80) 


PHIMOSIS    AND    PAEAPHIMOSIS.  81 

occurs  in  the  adult  from  retraction  of  the  prepuce  when  inflamed.  In 
both  chiklren  and  adults  paraphimosis  may  lead  to  serious  results.  Strangu- 
lation of  the  glans  and  gangrene  have  been  met  with.  As  a  rule,  however, 
the  constricting  band  produces  ulceration  upon  the  corona  glandis  and, 
becoming  itself  ulcerated,  finally  gives  way,  relieving  the  constriction  and 
preventing  gangrene  of  the  glans. 

Treatment. — The  treatment  of  phimosis  should  be  circumcision. 

Though  seemingly  a  simple  operation,  circumcision  has  been  performed 
in  a  great  variety  of  ways.  Some  little  nicety  of  manipulation  is  necessary 
to  obtain  a  really  excellent  result.  The  operation  is  best  performed  as 
follows:  If  adhesions  exist  they  should  be  separated  by  means  of  a  stout 
probe  or  director.  A  line  is  drawn  in  ink  just  in  front  of  the  corona  glandis; 
the  integument  being  drawn  moderately  well  forw^ard,  the  prepuce  should 
be  engaged  between  the  blades  of  a  pair  of  long  dressing  forceps  or  Eicord's 
or  Henry's  preputial  clamp.  The  tissues  should  be  excised  with  knife  or 
scissors  along  the  line  selected.  The  clamp  is  next  removed  and  the  skin 
allowed  to  retract,  after  which  it  will  be  found  that  a  mucous  layer  of  the 
prepuce  still  remains  over  the  glans  penis.  This  layer  should  be  slit  up 
wdth  scissors  in  the  median  line  of  the  dorsum  of  the  penis  nearly  as  far 
back  as  the  corona,  after  which  the  corners,  and  as  much  as  is  necessary  of 
the  free  border,  should  be  trimmed  off.  The  mucous  layer  is  now  turned 
back  like  a  coat-cuff  and  the  edges  of  the  skin  and  quasimucous  membrane 
accurately  apposed.  A  small  slit  should  be  cut  in  the  integumentary  border 
of  the  cut  surface  to  limit  strangulation  of  the  parts  when  swelling  occurs, 
as  it  inevitably  will.  This  procedure  gives  an  abundance  of  room,  and 
usually  prevents  tearing  out  of  the  stitches  under  the  pressure  of  inflam- 
matory swelling. 

The  hemorrhage  having  been  checked,  a  series  of  interrupted  sutures 
should  be  introduced  sufficiently  close  together  to  insure  close  apposition 
of  the  cut  edges.  The  first  stitch  should  be  exactly  in  the  median  line 
on  the  dorsum  of  the  penis  and  the  second  at  the  frenum  preputii,  the 
others  being  inserted  at  regular  intervals.  A  dressing  of  dry  iodoform  and 
gauze  should  be  applied,  and  the  patient  kept  quiet  until  complete  union 
has  taken  place.  If  erections  prove  annoying,  the  cold-water  coil  may  be 
used.  The  bromids,  chloral,  and  hyoscyamus  may  be  required  to  allay 
erections.  The  patient  should  be  warned  against  getting  up  too  soon,  a  week 
or  ten  days  being  usually  necessary  for  complete  union.  The  stitches  may 
be  removed  on  the  third  day  and  the  wound  redressed.  Should  the  patient 
get  about  too  soon,  the  edges  of  the  wound  will  quite  likely  gape,  the  result- 
ing cicatrix  proving  a  source  of  great  annoyance.  Where  healing  by  granu- 
lation occurs,  the  line  of  cicatrix  may  remain  tender  for  months,  and  so 
obstruct  the  circulation  in  the  distal  portion  of  the  prepuce  that  the  organ 
is  swollen  and  sensitive  for  an  indefinite  time. 

Although  sometimes  advisable,  sutures  are  unnecessary  in  infants.    The 


82 


DISEASES    OF    THE   PEXILE   INTEGUMEXTS. 


mucous  membrane  should  be  rolled  back  over  the  glans  so  that  the  cut 
surfaces  come  into  apposition.  They  may  be  retained  in  position  by  a 
square  of  gauze  or  linen  smeared  with  vaselin,  in  the  center  of  which  a 
small  hole  has  been  cut  for  the  glans.  In  children  several  years  of  age  it 
is  well  to  insert  four  fine  stitches. 

When  the  phimosed  prepuce  is  not  very  redundant,  circumcision  is 
not  absolutely  necessary.  It  is  practicable  to  stretch  the  orifice  of  the  pre- 
puce from  time  to  time,  finally  accomplishing  sufficient  dilation  to  permit 
exposure  of  the  glans. 

In  some  cases  of  inflammatory  j)himosis  a  dorsal  incision  only  is  war- 
rantable for  the  time  being.     Circumcision  should  follow  later  on. 

General  anesthesia  is  unnecessary  in  circumcision.     Cocain  may  be 


Fig.  10. — Operation  for  phimosis. 


safely  and  effectively  used  hypodermically.  The  Schleich  method  is  effi- 
cient. Whatever  method  be  used,  the  drug  should  not  be  used  in  solutions 
stronger  than  1,  or  at  most,  2  per  cent,  in  1-per-cent.  solution  of  carbolic 
acid.  In  infants  painting  the  glans  and  delicate  reflexion  of  the  prepuce 
with  a  4-per-cent.  solution  of  cocain  in  1-per-cent.  carbolic  solution  is 
usually  sufficient.  When  cocain  is  used  hypodermically  the  root  of  the  organ 
should  be  encircled  by  a  rubber  constrictor,  the  solution  being  injected  just 
in  front  of  it.    This  limits  the  action  of  the  drug. 

Paraphimosis  may  often  be  reduced  manually:  The  glans  should  first 
be  well  lubricated  with  vaselin  or  oil.  The  organ  is  now  encircled  with 
the  fingers  just  behind  the  constricted  point,  and  the  prepuce  is  drawn 
forward  by  steady  traction,  the  glans  penis  being  simultaneously  compressed 


BALANITIS    AND    POSTHITIS.  83 

by  the  thumbs.  If  necessary,  an  anesthetic  may  be  given.  This  procedure 
will  rarely  fail,  unless  paraphimosis  has  existed  for  some  time  and  con- 
siderable inflammation  and  swelling  exist.  Should  it  be  found  impossible 
to  draw  the  prepuce  forward,  the  knife  will  be  necessary.  The  preputial 
constriction  should  be  nicked  at  as  many  points  as  necessary  to  relieve  the 
strangulation,  after  which  an  attempt  should  be  made  to  draw  the  prepuce 
forward.  If  the  prepuce  is  so  infiltrated  that  it  cannot  be  drawn  forward 
even  after  incision,  the  patient  should  be  put  to  bed  and  hot  applications 
ased.  Within  a  few  days,  or  perhaps  hours,  the  swelling  will  have  subsided, 
so  that  the  prepuce  may  be  drawn  into  its  natural  position. 

If  gangrene  has  already  occurred,  poultices  of  charcoal  and  yeast  or  hot 
bichlorid  solution  and  gauze,  should  be  applied  until  the  sloughs  come  away, 
after  which  the  process  should  be  treated  as  simple  ulcer.  Ulcerations  from 
paraphimosis  require  the  same  general  surgical  principles  as  under  other 
circumstances,  especial  care  being  taken  to  promote  cleanliness  by  prevent- 
ing accumulation  of  decomposable  secretions. 

Balanitis  and  posthitis — inflammation  of  the  mucous  layer  of  the 
prepuce  and  the  delicate  mucous  membrane  covering  the  glans  penis — are 
very  frequent.  These  conditions  may  occur  spontaneously  as  a  consequence 
of  highly-acid  urine  or  the  decomposition  of  various  secretions  which 
accumulate  beneath  the  prepuce  in  uncleanly  persons.  They  occur,  how- 
ever, in  those  who,  however  particular  they  may  be  regarding  the  toilet  of 
their  sexual  organs,  find  cleanliness  impossible  because  of  phimosis.  Bala- 
noposthitis  may  also  occur  as  a  complication  in  chancre,  chancroid,  and 
most  frequently  of  all  in  virulent  urethritis.  It  is  under  all  circumstances 
a  non-venereal  disease  per  se,  being  invariably  produced  by  irritation,  which 
may  depend  upon  the  presence  of  either  venereal  or  non-venereal  secretions 
and  may  or  may  not  be  derived  through  sexual  intercourse.  When  the  in- 
flammation has  existed  for  some  little  time,  there  occurs,  in  many  instances, 
— especially  where  the  source  of  the  irritation  is  the  secretion  of  gonorrhea 
or  chancroid, — excoriation  of  the  mucous  membrane.  The  delicate  epi- 
thelium covering  the  glans  first  becomes  macerated,  then  abraded,  and  at 
various  points  small  ulcers  may  develop  that  may  be  mistaken  for  true 
venereal  ulcers.    Another  condition  that  may  arise  is  venereal  vegetations. 

The  secretions  of  balanitis  and  posthitis  are  not  inoculable  in  the  strict 
sense  of  the  word,  unless  gonorrhea,  chancroid,  or  true  syphilitic  chancre 
be  present,  in  which  case  we  have  an  admixture  of  specific  with  non- 
specific secretions. 

Balanitis  may  give  rise  to  bubo  of  a  simple  inflammatory  character, 
which  may  suppurate. 

Balanitis  may  be  mistaken  for  gonorrhea  or  chancroid.  Autoinocula- 
tion  will  differentiate  it  from  the  latter,  and  inspection,  before  or  after  pre- 
putial retraction,  will  exclude  urethritis.  There  is  no  period  of  incubation 
in  balanitis,  and  the  disease  is  variable  in  its  course. 


84  DISEASES    OF    THE    PEXILE    IXTEGUMEXTS. 

Treatment. — The  treatment  of  balanitis  and  posthitis  consists  of  meas- 
ures to  promote  cleanliness  and  the  application  of  mild  astringent  washes 
or  dry  absorbent  powders,  the  powdered  oleate  of  zinc,  stearate  of  zinc, 
calomel,  lycopodinm,  and  oxid  of  zinc,  all  being  useful.  In  some  cases  it 
is  necessary  for  the  patient  to  wear  a  small  ring  of  absorbent  cotton  about 
the  glans  penis  under  the  prepuce.  If  changed  frequently  this  will  keep 
the  parts  dry.  "Wlien  attacks  of  balanitis  recur  repeatedly,  circumcision  is 
demanded.  If  in  the  course  of  the  case  the  prepuce  becomes  greatly  swelled 
and  phimosed,  a  dorsal  incision  may  be  necessary  to  expose  the  glans  and 
relieve  tension. 

Pexile  acxe  may  appear  as  pustules  or  papules  upon  the  skin,  very 
rarely  upon  the  quasimucous  membrane.  It  may  result  either  from  general 
debility  in  combination  with  local  irritation  or  from  infection  with  pus- 
microbes  alone.  Small  acneic  pustules  sometimes  form  about  ordinary 
comedo  of  the  integument  of  the  penis. 

In  appearance  the  disease  is  similar  to  acne  in  other  situations.  The 
diagnosis  is  usually  not  difficult,  the  lesions  being  totally  unlike  chancre  and 
chancroid.  The  absence  of  autoinoculability  and  the  history  of  the  case, 
in  addition  to  the  physical  characters  of  the  lesions,  usually  serve  to  differ- 
entiate the  condition  from  both  forms  of  venereal  sore.  Acne  may,  how- 
ever, occur  upon  the  mucous  membrane  as  a  pustule  closely  resembling 
follicular  chancroid.     Again,  acne  may  precede  a  venereal  sore. 

Treatment. — The  treatment  of  penile  acne  consists  of  attention  to  the 
general  health,  the  promotion  of  cleanliness,  the  application  of  soothing 
lotions,  and  incision  of  the  pustules. 

Eczema  of  the  pexis  is  occasionally  seen,  and  is  usually  coincidental 
with  eczema  scroti.  It  sometimes  proves  very  obstinate.  A  case  which 
recently  came  under  the  author's  observation  is  a  striking  illustration  of 
this.  The  patient  had  been  affected  with  eczema  of  the  penis  and  scrotum 
for  a  number  of  years,  the  condition  being  limited  to  these  parts.  The 
integument  and  mucous  membrane  were  extensively  infiltrated,  fissured, 
and  excoriated.  So  severe  was  the  disease  that  intercourse  had  become  a 
practical  imjoossibility,  and  the  itching  and  irritation  made  the  life  of  the 
patient  most  miserable.  The  case  had  passed  through  the  hands  of  a  number 
of  competent  physicians,  none  of  whom  had  been  able  to  give  permanent 
relief.  Under  applications  of  a  mild  solution  of  salicylic  acid  and  the  inter- 
nal administration  of  arsenic  slight  improvement  occurred,  but  the  patient 
finally  became  discouraged  and  stopped  treatment.  Some  of  these  cases  are 
gout}^  and  may  be  cured  by  hydrotherapy  and  dietetics. 

Treatment. — The  treatment  of  genital  eczema  is  essentially  the  same  as 
that  of  other  forms  of  the  disease. 

HePlPES  Peogexitalis. — This  is  a  most  important,  though  relatively 
harmless  disease.  It  is  important  chiefly  from  its  frequent  occurrence,  the 
moderate  amount  of  local  irritation  it  sometimes  produces,  its  demoralizing 


HEKPES    PKOGEXITALIS. 


85 


effect  upon  the  mind  of  the  patient,  and  its  liability  to  be  mistaken  for 
other  diseases.  It  consists  of  a  development  of  small  vesicles  filled  with 
watery,  sometimes  sero-purnlent,  fluid  upon  the  skin  or  mucous  membrane 
of  the  genitals.  It  is  rarely  seen  in  the  female,  although  in  Hebra's  atlas 
there  is  an  excellent  representation  of  the  disease  in  a  woman.  According 
to  Unna,  the  disease  is  not  so  very  infrequent  in  women,  and  Duhring 
claims  he  has  never  seen  it  in  Avomen.  It  is  possible,  as  Unna  says,  that 
women  are  just  as  susceptible  to  herpes  as  men,  and  that  females  are  not 
immune,  but,  if  so,  its  apparent  rarity  must  be  due  to  the  protected  situa- 
tion of  the  lesions  which  prevents  discovery. 

According  to  Legendre,  Fournier,  and  Bruno,  the  coincidence  of  an 
herpetic  eruption  with  menstruation  is  not  infrequent.  In  some  women 
it  develops  shortly  before  every  menstrual  epoch.  The  author's  personal 
experience  is  limited  to  a  single  case:  a  lady  who  suffers  from  a  crop  of 
herpetic  vesicles  and  ulcerations  about  the  inferior  commissure  of  the  vulva 
at  every  period  of  menstruation.  These  are  very  annoying  from  pain  and 
smarting,  the  act  of  urination  being  very  distressing.  With  some  attacks 
there  occurs  marked  edema  of  the  genitals.  An  interesting  case  of  herpes 
apparently  dependent  upon  menstruation  recently  came  under  observa- 
tion in  which  the  eruption,  instead  of  being  located  upon  the  genitals, 
appears  between  the  fingers.  It  comes  on  a  few  days  prior  to  menstruation, 
and  lasts  for  a  day  or  two  after  its  cessation.  During  this  time  consider- 
able neuralgic  pain  in  the  arm  and  hand  is  complained  of.  The  author  has 
seen  one  case  in  which  herpes  progenitalis  repeatedly  occurred  with  preg- 
nancy and  at  no  other  time. 

Diagnosis. — The  diagnosis  of  herpes  progenitalis  in  uncomplicated 
cases  of  the  affection  is  comparatively  easy.  There  is  usually  a  history  of 
recurrent  crops  of  vesicles  and  minute  ulcerations,  perhaps  independently 
of  sexual  intercourse.  In  the  larger  proportion  of  cases  there  is  no  definite 
relation  to  any  particular  act  of  intercourse;  even  when  due  to  irritating 
materials  deposited  upon  the  mucous  membrane  during  uncleanly  inter- 
course, the  affection  comes  on  at  a  variable  interval  thereafter,  in  some  in- 
stances the  eruption  appearing  within  a  day  or  two,  in  others  not  for  several 
weeks. 

Etiology. — The  cause  of  herpes  progenitalis  is  usually  said  to  consist  of 
local  irritation,  but  it  would  seem  probable  that  a  great  majority  of  cases 
depends  upon  a  neurosis.  In  this  the  disease  strongly  resembles  herpes  zoster. 
Some  patients  of  a  highly  irritable,  nervous  temperament,  readily  subject  to 
nervous  depression,  and  perhaps  suffering  from  more  or  less  general  debility, 
are  affected  at  frequent  intervals  by  successive  attacks  of  herpes  of  the 
genitals.  Malarial  infection  may  produce  herpes  progenitalis,  as  well  as 
other  forms.  Unna  is  inclined  to  regard  herpes  progenitalis  as  rudimentary 
herpes  zoster  and  calls  attention  to  the  limitation  of  herpes  zoster  and 
herpes  progenitalis  to   peripheral  points   of  nerve-distribution.     In   some 


86  DISEASES    or    THE    PENILE   INTEGUMENTS. 

cases  herpes  progenitalis  is  apparently  due  to  disturbance  of  the  parts  in- 
cidental to  pregnancy  and  menstruation  in  the  female.  Uncleanliness, 
decomposing  secretions^  hot  weather,  obesity,  forcible  attempts  at  inter- 
course, impeded  erection  due  to  redundant  prepuce,  excessive  venery,  and 
masturbation  are  all  capable  of  causing  excessive  congestion  of  the  genital 
organs,  which  the  author  believes  to  be  the  essential  condition  upon  which 
herpes  progenitalis  depends.  Imperfect  or  perverted  sexual  hygiene  is 
peculiarly  liable  to  give  rise  to  more  or  less  congestion  of  the  genitalia,  with 
attendant  disturbance  of  the  delicate  nerves  supplied  to  these  parts.  That 
this  condition  of  affairs  may  give  rise  to  trophic  changes  in  the  mucous  mem- 
brane and  skin,  as  evidenced  by  the  occurrence  primarily  of  vesicles  and  sec- 
ondarily of  ulceration,  is  highly  probable. 

There  has  been,  so  far  as  the  author  is  aware,  no  mention  made  by 
writers  of  the  possible  causal  relation  of  syphilis  to  herpes  progenitalis. 
Many  cases,  however,  seem  to  be  directly  dependent  upon  the  syphilitic 
cachexia.  Syphilitic  patients  return,  from  time  to  time,  with  apparently 
typic  crops  of  herpes  upon  the  genitalia.  These  cases  are  usually  obsti- 
nate to  all  local  measures,  excepting  the  application  of  mercurials.  Tonic 
and  mild  antisyphilitic  remedies  are  also  required  internally.  The  author 
attributes  the  herpes  in  such  cases  to  several  causes: — 

1.  (In  some  cases)  Local  irritability  incidental  to  the  chancre  or  mixed 
sore  that  originally  initiated  the  patient  in  his  venereal  experience. 

2.  Disturbed  innervation  and  consequent  trophic  changes — incidental 
to  the  effects  of  the  syphilitic  infection,  excessive  medication  (with  mer- 
cury especially),  and  mental  worry  upon  the  sympathetic  sj^stem. 

Herpes  progenitalis  rarely  affects  the  integument  of  the  penis,  scrotum, 
and  thighs,  being  limited  usually  to  the  glans.  Unna  states  that  the  erup- 
tion almost  invariably  corresponds  with  the  course  of  the  ramus  dorsalis 
penis:  a  branch  of  the  pudic  nerve.  The  author,  however,  has  not  noted 
any  regularity  of  distribution  of  the  herpetic  vesicles.  Cases  limited  to 
the  skin  of  the  organ  are  sometimes  observed. 

The  pain  of  herpes  progenitalis  is  usually  insignificant.  If,  however, 
urine  be  brought  in  contact  with  the  little  ulcerations  left  after  the  rupture 
of  the  vesicles,  the  part  becomes  exceedingly  tender  and  much  burning 
and  smarting  are  complained  of.  The  disease  may  develop  just  at  the 
borders  of  the  meatus  urinarius  and  occasionally  Just  within  it.  In  one  of 
the  author's  cases  a  row  of  some  half-dozen  small  herpetic  vesicles  develops 
upon  the  right  side  of  the  meatus  from  time  to  time,  while  in  another 
there  is  an  occasional  development  of  herpetic  spots  just  inside  the  orifice. 
In  these  cases  there  is  considerable  pain  and  smarting  during  urination, 
and  the  disease  seems  to  develop  coincidently  with  nervous  depression. 

Differentiation. — The  diseases  for  which  herpes  is  most  likely  to  be  mis- 
taken are  chancre  and  chancroid.  There  is,  of  course,  no  difficulty  in  the 
differential  diagnosis  of  herpes  from  typic  chancre  and  chancroid  when 


HERPES    PROGENITALIS.  87 

these  are  fully  developed,  but  in  their  incipiency  mistakes  may  be  made. 
Fortunately,  however,  a  few  days'  study  of  the  case  will  generally  clear  up 
the  diagnosis. 

Chancroid  often  begins  as  a  small  herpetiform  vesicle  or  perhaps  group 
of  vesicles  or  ulcers.  This  is  probably  because  the  chancroidal  or  other 
irritating  germ  inoculated  during  intercourse  produces  primarily  herpes, 
by  simple  irritation,  chancroid  afterward  developing  at  the  site  of  the 
herpetic  lesions.  The  same  explanation  holds  good  in  some  cases  of  hard 
chancre.  The  so-called  'Tierpetiform  chancre"  is  probably  explicable  in 
this  way.  Unna  has  noticed  a  form  of  initial  sore  that  is  probably  her- 
petiform chancre.  According  to  him,  chancres  in  the  male  may  occur  on 
the  inner  surface  of  the  prepuce  which  are  benign  in  appearance  and  slowly 
involve  the  surrounding  tissues,  resembling,  at  first  sight,  herpetic  erosions. 
These  are  chancres  involving  Tyson's  glands,  which  develop  as  slight  epi- 
thelial proliferations  in  small  contiguous  groups  of  sebaceous  glands.  The 
round  follicular  openings  are  eroded,  abnormally  patulous,  and  acutely 
hyperemic,  resembling  an  herpetic  erosion.  The  typic  herpetic  course 
being  followed,  slight  induration  becomes  manifest,  succeeded  by  disintegra- 
tion and  confluent,  rapidly-spreading  ulceration,  resembling  soft  chancre. 
These  exceptional  cases  may  lead  to  an  unjustly-favorable  prognosis. 

In  cases  in  which  true  syphilis  follows  an  apparently  herpetiform  lesion 
of  the  genitalia  there  will  probably  always  be  found  upon  close  inspection, 
if  the  case  be  carefully  watched  from  day  to  day,  a  certain  degree  of 
chanerous  induration.  An  important  source  of  error  in  the  diagnosis  and 
prognosis  of  certain  atypic  genital  lesions  is  that  physicians  do  not  watch 
their  cases  with  sufficient  care,  and  are  prone  to  give  a  dogmatic  opinion 
without  considering  the  many  sources  of  confusion.  If  these  cases  were 
more  carefully  studied,  it  is  highly  probable  that  many  of  those  cases  of 
syphilis  which  have  apparently  followed  simple,  non-indurated  lesions  of 
an  herpetic,  simple  ulcerative,  or  chancroidic  character  would  be  foimd  to 
have  been  preceded  by  induration  that  developed  after  the  simple  sore  had 
apparently  healed,  when  the  patient's  attention  was  no  longer  directed  to 
the  local  difficulty.  Again,  as  will  be  seen  in  connection  with  the  diagnosis 
of  syphilis,  induration  may  be  transitory  and  thus  escape  attention  unless 
the  lesion  be  studied  with  extreme  care  from  day  to  day. 

When  herpetic  ulcerations  become  inflamed  they  may  closely  resemble 
true  chancroid.  Indeed,  under  certain  circumstances  herpetic  and  balanitic 
ulcers,  or,  for  that  matter,  ulcerations  of  any  sort  whatsoever,  may  become 
transformed  into  the  physical  characters  of  a  mild  type  of  chancroid.  This 
statement  is  made  with  due  appreciation  of  the  wide  clinical  differences 
between  typic  herpes  and  typic  chancroid.  Eeferring  to  the  possibility 
of  superadded  infection  in  herpes,  a  word  of  caution  is  necessary.  A  posi- 
tive opinion  should  never  be  passed  upon  the  character  of  herpes  progeni- 
talis,  or,  indeed,  of  any  apparently  non-specific  lesion  of  the  genitalia  in 


05  DISEASES    OF    THE    PENILE    INTEGUMENTS. 

cases  in  which  there  has  been  a  more  or  less  recent  suspicious  exposure. 
The  patient  should  be  made  to  understand  the  possibility  of  a  syphilitic  or 
chancroidal  infection  which  has  not  yet  developed  and  which  there  are  no 
means  of  detecting  prior  to  the  appearance  of  the  specific  sore. 

Ti'eatment. — The  treatment  of  herpes  progenitalis  is^  in  the  majority  of 
instances,  simple  and  successful,  but  the  disease  is  sometimes  very  obstinate. 
Mild  dusting-powders  or  astringent  washes  are  usually  sufficient.  A  most 
efl&cient  powder  is  the  stearate  of  zinc.  Calomel,  oxid  or  oleate  of  zinc,  sub- 
nitrate  or  subcarbonate  of  bismuth,  and  lycopodium,  singly  or  in  various 
combinations,  are  all  useful.  A  mildly-astringent  wash  of  iodid  of  zinc,  5 
or  10  grains  to  the  ounce,  or  alum,  in  a  strength  of  20  or  30  grains  to  the 
ounce,  may  be  used  as  a  lotion.  It  may  become  necessary  to  touch  the  her- 
petic spots  with  nitrate  of  silver.  Wlien  the  lesions  are  very  painful  mor- 
phin  or  cocain  may  be  added  to  the  dusting-powder.  The  essential  point  in 
the  treatment  is  to  keep  the  parts  clean  and  dry.  In  some  instances  cir- 
cumcision is  advisable.  In  many  cases  constitutional  measures  are  necessary. 
Tonics — such  as  quinin,  iron,  and  strychnin,  and,  where  there  is  much 
nervous  irritability,  bromid  of  potassium — are  indicated.  In  some  chronic 
cases  arsenic  will  be  found  useful. 

In  the  solitary  case  of  menstrual  herpes  that  the  author  has  seen,  the 
bromids,  with  very  small  doses  of  ergot  for  a'  week  or  ten  days  prior  to 
menstruation,  has  proved  of  some  benefit,  although  the  patient  is  by  no 
means  cured.  In  some  cases  of  genital  herpes  in  the  male  the  occasional 
passage  of  a  sound  will  prove  beneficial  by  relieving  nervous  irritability, 
congestion,  and  sexual  excitability.  In  a  general  way  the  sound  may  be 
said  to  improve  the  tone  of  the  genital  organs.  Some  obstinate  cases  are 
apparently  cured  by  matrimony.  A.  few  cases  will  appear  absolutely  resist- 
ant to  treatment,  yet  may,  at  any  time,  recover  spontaneously. 

Simple  Ulcer. — Simple  ulcer  of  the  genitals  is  so  intimately  associated 
with  balanitis  and  herpes  that  it  hardly  deserves  separate  consideration. 
Sometimes,  however,  in  the  course  of  gonorrhea,  chancroid,  or  chancre,  small 
ulcers  appear  upon  the  quasimucous  membrane  that  are  apparently  due  to 
irritation  produced  by  the  products  of  inflammation.  In  uncleanly  persons 
simple  ulcers  of  a  benignant  appearance  may  occur  that  are  apparently  due  to 
uncleanliness.  Eetention  of  irritating  secretions  in  phimosis  may  give  rise 
to  simple  ulceration  with  or  without  the  intervention  of  balanitis.  Herpes 
may  be  followed  by  simple  ulcers  of  greater  or  less  extent  and  persistency. 
This  Avill  quite  likely  occur  if  the  herpes  is  neglected  or  the  patient 
uncleanly.  Simple  ulcer  is  important  chiefly  on  account  of  its  close  simula- 
tion of  true  chancroid  if  it  be  subjected  to  sources  of  irritation.  The 
line  of  demarkation  between  simple  ulcer  and  chancroid  is  the  autoinocula- 
bility  of  the  latter;  but,  as  will  be  seen  later  on,  this  may  be  a  difference 
in'  degree  rather  than  kind.  The  products  of  simple  ulceration  may,  under 
favorable  circumstances,  produce  a  sore  in  another  situation  that  may  not 


LYMPHANGITIS.  89 

always  be  clue  to  mere  pus-infection.  The  fact  that  the  secretion  of  a 
chancroid  produces,  when  inoculated,  a  sore  precisely  similar  to  that  from 
which  the  secretion  was  derived  is  probably  dependent  upon  the  circum- 
stance that  the  poison  (germ)  of  chancroid  is  more  highly  elaborated  (differ- 
entiated) than  the  irritating  germs  and  germ-products  of  simple  ulceration. 
This  does  not  necessarily  imply  that  the  origin  of  the  two  diseases  may 
not,  under  certain  circumstances,  be  precisely  similar.  Again,  chancroid 
after  a  yariable  time  loses  its  property  of  infection,  and,  while  physically 
it  is  none  the  less  a  chancroid,  it  is  practically  no  more  noxious  than  any 
simple  ulcer  and  takes  the  same  course.  The  author  thus  expresses  him- 
self with  due  cognizance  of  the  Duerey-Unna  bacillus — the  alleged  specific 
germ  of  chancroid. 

Treatment. — The  treatment  of  simple  ulcer  consists  of  measures  of 
cleanliness,  mild  astringents,  and  the  proper  management  of  the  particular 
disease  to  which  it  may  be  secondary.  Care  should  be  taken  not  to  inflame 
or  irritate  the  part  by  overvigorous  measures. 

Lymphangitis  of  the  Integuments  of  the  Penis. — This  is  almost 
invariably  secondary.  Any  disease  giving  rise  to  irritating  products  capable 
of  absorption  by  the  capillary  lymphatics  (as  is  true  of  all  inflammations, 
sim]Dle  or  specific)  may  be  complicated  by  lymphangitis.  Perhaps  the  most 
frequent  disease  that  produces  it  is  virulent  urethritis.  It  is  apt  to  occur, 
however,  in  the  course  of  true  syphilitic  chancre  as  a  consequence  of  local 
irritation  and  mixed  infection.  The  chronic  infiltration  of  the  lymphatic 
vessels  that  occurs  in  the  natural  course  of  syphilis  should  not  be  regarded 
as  true  lymphitis,  but  rather  as  hyperplasia  produced  by  rapid  proliferation 
of  both  normal  and  syphilitic  cells  in  the  lymphatic  structures. 

Chancroid  is  likely  to  be  followed  or  accompanied  by  inflammation  of 
the  lymphatics  of  the  prepuce.  This  may  be  localized  in  one  or  more 
lymphatic  vessels  leading  from  the  chancroid  to  the  root  of  the  penis,  or 
it  may  be  diffuse  and  superficial,  causing  a  uniform  thickening  of  the  penile 
integument.  In  the  course  of  chancre  or  chancroid,  inflammation  from 
mixed  infection  sometimes  occurs  about  the  lymphatic  vessels  (perilym- 
phitis).     This  may  cause  suppuration  without  involving  the  vessel  proper. 

Lymphitis  or  lymphangitis  of  an  erysipelatous  character  may  result 
from  streptococcic  infection;  this  may  go  on  to  true  phlegmonous  erysipelas 
or  diffuse  cellulitis. 

Operations  about  the  penis  followed  by  infection  may  give  rise  to  in- 
flammation of  the  lymphatics,  indicated  by  redness,  swelling,  edema,  or  per- 
haps tension  of  the  prepuce.  In  diffuse  lymphitis  there  is  often  consider- 
able constitutional  disturbance,  especially  if  erysipelatous  infection  exists. 
When  the  inflammation  is  limited  to  the  trunks  of  the  lymphatics,  more  or 
less  hardened,  reddened,  and  tender  longitudinal  lines  or  cords  may  be  felt 
beneath  the  skin  of  the  penis. 

The  process  may  remain  superficial  and  circumscribed.     It  may  in- 


90  DISEASES    OF    THE    PEXILE    IXTEGUMEXTS. 

crease,  causing  general  swelling  of  the  integuments  of  tlie  organ.  As  a  con- 
sequence of  lymphitis,  phimosis  or  paraphimosis  may  develop.  The  inflam- 
mation may  become  chronic,  the  prepuce  remaining  hardened,  thickened, 
infiltrated,  and  semicartilaginous  for  an  indefinite  time.  Suppuration  does 
not  usually  occur  in  lymphitis,  but  may  do  so  if  the  patient  be  debilitated, 
in  extensive  .pus-infection,  or  if  the  primary  process  be  chancroid.  Pus  may 
form  at  circumscribed  points  in  the  course  of  the  inflamed  lymphatic  vessels, 
or  may  diffusely  infiltrate  the  cellular  tissue  beneath  the  integument  of 
the  penis,  and  perhaps  cause  gangrene,  these  latter  cases  closely  resembling 
true  phlegmonous  erysipelas. 

Treatment. — The  treatment  of  lymphangitis  consists  chiefly  of  rest  and 
the  application  of  soothing  lotions,  such  as  lotio  plumbi  et  opii.  This  had 
best  be  applied  hot,  as  care  should  be  taken  not  to  depress  the  vitality  of  the 
tissues.  Ichthyol  is  valuable.  A  brisk  mercurial  purge  followed  by  salines 
should  be  given.  Aconite  or  veratrum  may  be  required.  If  suppuration 
seems  imminent,  or  the  prepuce  becomes  dusky  and  brawny,  free  incisions 
should  be  made,  these  being  the  best  prophylaxis  of  suppuration.  Anti- 
septic poultices  are  needed  where  phagedena  or  gangrene  develops.  The 
chronic  infiltration  and  thickening  of  the  prepuce  that  sometimes  follow 
acute  lymphitis  usually  demand  circumcision.  In  some  cases,  however, 
judicious  strapping  and  the  use  of  the  faradic  current  will  slowly  bring 
about  resolution.    Frequent  bathing  with  hot  water  is  a  valuable  adjuvant. 

Phlegmoxous  Erysipelas  of  the  Pexis. — This  usually  involves  the 
scrotum  and  occurs  occasionally  as  a  primary  disease — one  of  the  most  formi- 
dable that  the  surgeon  is  likely  to  meet  with.  The  disease  rarely  comes 
under  the  observation  of  the  general  practitioner,  or,  indeed,  of  any  save 
those  connected  with  public  institutions;  but  it  is  nevertheless  important 
on  account  of  its  invariably  serious  character.  It  occurs,  as  a  rule,  in 
broken-down,  debilitated  individuals  with  bad  hygienic  surroundings.  Its 
origin  is  usually  obscure,  it  being  often  impossible  to  trace  it  to  infection 
with  the  erysipelas  streptococcus.  The  author's  cases  have  nearly  all  been 
seen  in  hospital  practice,  and  were  contracted  outside  the  institution.  In 
none  of  them  was  there  a  history  of  traumatism  or  of  exposure  to  con- 
tagion.^ 

Symptoms. — The  disease  begins  with  a  greater  or  less  degree  of  swelling 
and  redness  of  the  part,  the  prepuce  speedily  becoming  edematous.  The 
organ  soon  becomes  excessively  swelled  and  infiltrated,  and  very  tender  to 
the  touch.  There  may  or  may  not  be  a  rigor.  The  temperature  is  likely  to 
be  relatively  high.  Bogginess,  followed  by  gangrene  and  extensive  slough- 
ing, is  likely  to  come  on  quite  rapidly. 


^  Since  the  above  was  ■written  the  author  has  seen  in  consultation  a  speedily  fatal 
case  of  this  type  of  infection  following  a  simple  meatotomy.  The  source  of  infection 
was  not  determined. 


GENITAL    PAPILLOMATA.  91 

The  constitutional  symptoms  are  characterized  by  great  depression. 
Septemia  or  pyemia  may  supervene. 

After  the  sloughs  have  separated,  the  tissues  soon  undergo  cicatrization. 
The  rapidity  of  repair  in  these  cases  is  astonishing.  The  author  has  seen 
the  skin  and  cellular  tissue  of  the  penis  and  scrotum  slough  completely 
away,  yet  healing  was  so  rapid  as  to  be  considered  phenomenal. 

The  prognosis  of  this  disease,  as  given  by  the  majority  of  authorities, 
is  very  unfavorable.  A  successful  result  is  not  to  be  expected  from  any  but 
the  most  radical  treatment,  which  often  saves  life. 

Treatment. — The  treatment  of  phlegmonous  erysipelas  of  the  penis  and 
scrotum  must  be  prompt  and  radical.  Free  incisions  should  be  made  in 
number  sufficient  to  completely  relieve  tension.  Hot  antiseptic  poultices 
or  wet  dressings  should  then  be  applied  until  the  sloughs  separate  and 
healthy  granulation  is  established,  when  the  process  should  be  treated  by 
dry  antiseptic  dressings,  followed  later  on  by  nitrate  of  silver  and  strapping. 

The  internal  treatment  should  comprise  a  nutritious  diet  and  free 
stimulation.  Iron,  quinin,  strychnin,  and  digitalis  are  always  indicated. 
The  tendency  to  asthenia  is  peciiliarly  marked,  and  supportive  measures 
should  be  relied  upon  early  and  late. 

G-ENiTAL  Papillomata. — Vegetations  or  papillomata  upon  the  mucous 
or  quasimucous  surfaces  of  the  genitals  in  both  sexes  are  popularly  known 
as  venereal  warts.  This  term  is  a  misnomer,  as  the  growths  are  in  no 
sense  venereal,  but  due  to  causes  entirely  independent  of  sexual  intercourse. 
They  may  be  met  with  in  persons  who  have  never  been  exposed  to  venereal 
infection.  They  are  frequently  found  in  pregnant  women,  in  whom  the  con- 
ditions favorable  for  their  development  very  often  exist,  particularly  among 
the  lower  classes,  to  whom  cleanliness  is  apparently  obnoxious.  The  condi- 
tions that  foster  these  papillary  overgrowths  resemble  in  many  respects  those 
essential  to  the  development  of  vegetable  fungi:  heat,  moisture,  and  filth, 
with  protection  from  air  and  sunlight.  Idiosyncrasy  and  local  nerve-per- 
turbation are  also  worthy  of  consideration  as  possible  etiologic  factors. 

In  the  case  of  fleshy  vegetations  upon  the  organs  of  generation  there 
exists,  in  addition  to  the  above-mentioned  conditions,  local  irritation  pro- 
duced by  the  products  of  simple  or  specific  inflammation  or  decomposing 
normal  secretions.  Secretions  occurring  about  the  ano-genital  region  in  un- 
cleanly persons  are  prone  to  decomposition,  and  when  decomposed  develop 
irritating  products  that  may  give  rise  to  inflammation  of  the  mucous  mem- 
brane in  balanitis  or  to  a  proliferation  of  the  epithelial  elements  of  the  part. 
Gonorrhea,  chancroid,  chancre,  balanitis,  balanoposthitis,  and,  indeed,  any 
affection  of  the  genitals  giving  rise  to  irritating  secretions,  may  result,  even 
under  the  best  of  care,  in  the  development  of  vegetations.  The  papillom- 
atous growths  consist  of  delicate,  rapidly-proliferating  epithelium  that  be- 
comes permeated  when  fully  developed  by  delicate  loops  of  capillaries;  they 
are  therefore  very  friable  and  extremely  vascular,   bleeding  freely  upon 


93 


DISEASES    OF    THE    PENILE    INTEGUMENTS. 


the  slightest  injury.  Genital  papillomata  may  grow  to  an  enormous  size; 
thus,  the  author  has  met  with  several  cases  in  which  vegetations  involving 
the  prepuce  and  glans  grew  to  the  size  of  an  orange.  In  a  case  occurring 
in  a  comparatively-cleanly  pregnant  Avoman  who,  so  far  as  known,  had 
never  suffered  from  any  venereal  disease,  the  vegetations  surrounded  the 
ostium  vagince  and  involved  the  tissues  about  the  anus,  forming  a  tumor 
not  unlike  a  large  cauliflower. 

In  passing,  the  author  desires  to  call  attention  to  the  fact  that  syphilis 
seems  to  hear  a  very  important  etiologic  relation  to  genital  vegetations. 


Fig.  11. — Venereal  vegetations.     (After  Taylor.) 


Syphilitics  are  esjDccially  prone  to  their  development  and  the  papillomatous 
growths  are  seemingly  very  resistant  to  treatment  in  such  patients.  The 
frequency  with  wdiich  genital  syphilides  become  transformed  into  exuberant 
vegetations,  with  a  distinct  and  positive  tendency  to  form  connective-tissue 
organization,  is  noteworthy. 

Treatment. — The  growths  should  be  treated  by  excision  with  the  knife 
or  scissors  or  destruction  by  caustics.  The  danger  of  hemorrhage  in  very 
large  growths  is  such  that  caustics  are  sometimes  preferable  to  excision, 
although,  if  the  surface  involved  is  not  very  extensive,  even  these  large 
growths  may  be  excised  and  their  bases  seared  with  the  actual  cautery.    Ex- 


GENITAL    PAPILLOMATA.  93 

cellent  results  may  soiiietimes  be  secured  by  injection  of  glacial  acetic  acid 
with  the  hypodermic  needle.  Small  growths  are  best  treated  by  excision 
with  scissors,  the  underlying  mucous  membrane  or  skin  being  removed  with 
the  growth.  If  necessary,  fine  stitches  may  be  inserted.  Chromic  acid  is 
one  of  the  best  caustics  for  the  destruction  of  venereal  vegetations.  It 
should,  however,  be  cautiously  used,  as  it  will  sometimes  cause  much  more 
extensive  destruction  than  desired.  Good  results  may  often  be  obtained  by 
imbedding  minute  grains  of  the  pure  acid  in  the  growth. 

Genital  papillomata  will  rarely  occur  if  proper  measures  of  cleanliness 
are  adopted.  Secretions,  whether  normal  or  morbid,  should  not  be  allowed 
to  accumulate  beneath  the  prepuce,  and  when  the  mucous  membrane  be- 
comes irritated  or  the  secretion  excessive  astringent  lotions  or  drying  pow- 
ders should  be  freely  used.  Circumcision  is  usually  demanded.  After  de- 
struction of  the  oTowths  the  mucous  membrane  should  be  treated  for  some 


Fig.  12. — Simple  penile  papillomata.     (After  White  and  Martin.) 

little  time  by  means  of  astringent  or  absorbent  powders  and  lotions  to  pre- 
vent their  recurrence.  In  the  majority  of  cases  vegetations  will  recur  to  a 
greater  or  less  extent  for  some  time  in  spite  of  treatment.  They  should  be 
removed  so  soon  as  detected.  Once  the  mucous  membrane  has  regained  its 
normal  condition  papillomata  will  no  longer  develop.  Constitutional  treat- 
ment is  often  essential  in  genital  papillomata.  Tonics,  and  especially  arsenic, 
are  often  valuable.  In  cases  with  a  specific  foundation  mercury  and  the 
iodids  are  necessary. 

The  conditions  remaining  in  the  preliminary  classification  of  penile 
diseases  do  not  demand  discussion  in  a  work  of  this  kind.  Lupus  erythem- 
atosus and  psoriasis  of  the  penis  present  the  same  features  as  when  in- 
volving other  portions  of  the  body,  and  properly  belong  to  the  department 
of  dermatology.  Syphilides  of  the  penis,  aside  from  their  tendency  to  papil- 
lomatous complication,  are  the  same  as  syphilides  in  general.  Chancre  and 
chancroid  will  receive  attention  later  on. 


PART  III. 

DISEASES  OF  THE  UEETHEA  AXD  GO^^OERHEA. 


CHAPTER  YIII. 

Diseases  of  the  Male  Urethra:    Anatomy  and  Physiology;    Teatj- 
iiATisMs;   Foreign  Bodies  and  Tumors  of  the  Urethra. 

The  urethra  is  a  musculo-membranous  tube  extending  from  the  meatus 
Tirinarius  to  the  bladder.  It  is  divided^  in  the  male,  into  three  portions:  the 
penile,  spongy,  or  pendulous  urethra;  the  membranous;  and  the  prostatic. 
The  "two  latter  constitute  the  fixed,  or  deep,  urethra.  The  spongy  urethra 
is  about  six  inches  in  length,  extending  from  the  meatus  to  the  triangular 
ligament,  where  it  Joins  the  membranous  portion.  The  latter  is  about 
three-fourths  of  an  inch  long,  extending  from  the  anterior  to  the  posterior 


Fig.  13. — The  fossa  navicularis.     (After  Cruveilhier.) 

layer  of  the  triangular  ligament.  The  remainder  of  the  urethra  is  included 
in  the  prostatic  portion,  which  is  about  one  and  one-fourth  inches  long. 
The  meatus  is  the  narrowest  portion  of  the  canal,  and  serves  the  purpose 
of  directing  the  outflowing  semen  and  urine.  The  meatus  varies  con- 
siderably in  size.  A  small  meatus  is  not  necessarily  an  indication  for  a 
surgical  operation,  but  if  a  small-calibered  orifice  is  associated  with  urethral 
disease  or  reflex  disturbance  of  the  genito-urinary  tract,  a  narrow  meatus  is 
surgically  important.  The  meatus  is  sometimes  narrow  because  of  the  com- 
paratively great  thickness  of  that  portion  of  the  glans  forming  the  floor  of 
the  fossa  navicularis,  the  dilated  portion  of  the  urethra  situated  within  the 
boundaries  of  the  glans  and  terminating  at  the  junction  of  the  latter  with 
the  corpora  cavernosa.  In  other  cases  narrowness  of  the  meatus  is  due  to  a 
thin  membranous  fold  at  the  inferior  commissure  of  the  orifice.  This  is 
dilatable,  and  offers  little  or  no  resistance  to  instrumentation,  the  contrary 
being  true  of  the  variety  of  narrowing  previously  mentioned.  Narrowness 
(94) 


ANATOMY    OF    THE    MALE   UEETHEA. 


95 


of  the  meatus  is  generally  congenital,  destructive  ulceration  being  the  usual 
cause  of  acquired  contraction.  In  some  instances  the  canal  is  relatively 
narrow  because  of  the  presence  of  a  congenital  band  just  within  the  meatus, 
the  orifice  proper  being  fairly  dilatable.  On  the  roof  of  the  fossa  navicularis 
is  a  valve-like  fold  of  mucous  membrane  forming  a  small  pouch — the 
lacuna  magna — that  often  becomes  the  seat  of  chronic  infection  which  per- 
petuates urethritis. 

The  spongy  urethra  is  so  called  because  it  is  surrounded  by  the  corpus 
spongiosum.  The  mucous  membrane  of  this  portion  of  the  canal  is  abun- 
dantly supplied  with  mucous  glands  and  ducts.  These,  if  infected,  are  likely 
to  become  dilated  and  their  orifices  obstructed,  with  a  resultant  accumula- 
tion of  infectious  products  in  the  glands.  Latent  infection  and  successive 
gonorrheal  autoinfections  are  often  explained  thereby.     These  ducts  and 


Fig.  14. — Showing  lacuna  magna.  A,  Spongy  urethra.  B,  Fossa  navicularis. 
G,  Probe  separating  valve-like  fold  from  roof  of  lacuna  magna.  D,  Lacuna 
magna.     (After  Bumstead  and  Taylor.) 


follicles  may  be  so  dilated  as  to  catch  the  points  of  instruments  in  the  ex- 
ploration of  the  urethra.  They  may  also  be  the  point  of  departure  of  uri- 
nary abscess  and  fistula.  Their  abundance  and  the  difficulty  of  rendering 
them  aseptic  explains  the  obstinacy  of  some  cases  of  urethritis. 

The  membranous  urethra  is  invested  by  longitudinal  and  circular  fibers 
— the  compressor-urethrce  and  accelerator-urince  muscles.  On  this  account 
it  is  also  known  as  the  muscular  portion.  Its  function  is  very  important, 
as  it  is  the  true  sphincter  of  the  bladder.  This  is  under  volitional  control, 
but  in  rather  a  peculiar  fashion.  To  the  sympathetic  nerve-supply  of  the 
muscle  its  normal  tonicity  is  due.  The  voluntary  nerve-fibres  make  it 
possible  to  inhibit  the  normal  contraction  at  will,  consequently  the  normal 
tonus  of  the  detrusor  urince  is  enabled  to  overcome  the  slight  remaining 


96 


DISEASES    OF    THE    MALE    UEETHEA. 


resistance  of  the  true  sphincter,  witli  resulting  micturition.  Direct  or  reflex 
excitation  of  the  membranous  urethra  may  cause  retention  of  urine.  Con- 
versely, paralysis  of  it  produces  incontinence. 

Tlie  prostatic  urethra  will  receive  attention  in  connection  with  the 
anatomy  of  the  prostate. 

The  anatomic  relations  of  the  jDerineal  portion  of  the  urethra  are  of 
most  vital  surgical  importance;  esjDecially  is  this  true  of  the  relation  of  the 
bulbous  and  membranous  portions  to  the  triangular  ligament.  These 
anatomic  relations  are  of  the  greatest  importance  in  their  bearing  upon  the 
surgery  of  the  prostate  and  bladder.  The  dissections  of  the  perineum  as 
presented  in  Gray's  "Anatomy"' — reproduced  herewith — give  the  clearest 
possible  idea  of  the  anatomy  of  the  perineum.  It  is  well  for  the  surgeon 
who  is  not  a  practical  anatomist  to  review  these  plates  before  the  per- 
formance of  important  operations  in  this  region,  whether  the  operation  be 


Fig.  15. — Diagrammatic  section  of  perineum,  showing  arrangement  of  the  tri- 
angular ligament  (deep  perineal  fascia),  a,  Corpus  cavernosum.  b,  In- 
ferior layer  of  triangular  ligament,  c,  Transversus  perinei  muscle,  d, 
Urethra,  e,  Cowper's  glands,  f,  Superior  layer  of  triangular  ligament. 
g,  Internal  pudie  artery.  It,  Internal  pudic  nerve,  i,  Descending  ramus 
of  ischium.  ;,  Superficia]  fascia.  A".  Erector-penis  muscle.  J,  Bulb. 
m,  Accelerator-urinae  muscle,  n,  Superficial  fascia,  o,  Superficial  perineal 
artery,    p,  Superficial  perineal  nerve,    q,  Skin.     (After  Tillaux.) 


perineal  section,  cystotomy,  lithotomv,  or  radical  methods  of  dealing  with 
the  prostate. 

While  the  urethra  is,  under  normal  circumstances,  a  urinary  organ,  it 
is  not  necessary  to  micturition.  It  is,  however,  necessary  to  the  procreative 
act.     The  urethra  is,  therefore,  a  sexual  rather  than  a  urinary  organ. 

The  length  of  the  urethra  as  given  by  most  anatomists  is  from  eight 
to  nine  inches,  but  there  is  great  discrepancy  upon  this  point.  The  esti- 
mates of  various  clinical  observers  show  a  marked  variance  of  opinion.  A 
difference  of  from  20  to  30  per  cent,  in  the  estimated  measurements  of 
equally  competent  observers  is  neither  unusual  nor  surprising.    It  is  prob- 


ANATOMY  OF  THE  UEETHEA. 


97 


able  that  no  two  observers  can  obtain  precisely  similar  conditions  for  meas- 
urement.    The  penis  varies  in  size  not  only  in  different  subjects^  but  there 


CvngvrV  GUod 


Fig.  16. — Dissection  of  perineum,  showing  relation  of  bulb  of  urethra  to  the 
triangular  ligament.     (After  Gray.) 

is  great  variation  in  the  same  subject  under  different  psychologic  condi- 
tions. 


Cruvtr't  Giant/- 


Aif*rj  °f  Corpiu  Cattrnaim 
Uarta/  Arbr/f  ff  ft 


Artiry  f/  Buli. 
Zntimal  PaJic  Artery 


Fig.  yi. — Dissection  of  perineum,  showing  deeper  jjarts  in  their  relation  to 
the  urethra.     (After  Gray.) 


The  individual  urethra  is  a  law  unto  itself  as  regards  its  length.     The 
length  of  any  particular  urethra  may  be  fairly  said  to  be  the  distance  from 


98 


DISEASES    OF    THE    MALE    UEETHRA. 


the  meatus  traversed  by  the  catheter  before  the  urine  begins  to  flow,  the 
penis  being  flaccid  and  Just  tense  enough  for  adequate   support   during 


Fig.   18. — Xormal  cuive   of  luetlua.     (/,   Prostatic   portion,      h.   ^Membranous 
portion,     c.  Spongy  portion. 

instrumentation.     Allowance  should  be  made  for  sexual  excitation  or  emo- 
tional inhibition  of  blood-supply. 

The  physiologic  functions  of  the  urethra  bear  an  important  relation  to 
the  study  and  treatment  of  its  diseases.     While  the  urethra  is  of  sexual 


Fig.   19. — Bell's  curve,  showing  relation  of   (E)    Englisli,    (A)    American,  and 
{B)  Benique  sounds  to  it,  and  comparative  length  of  beaks. 


rather  than  urinary  importance,  both  functions  must  be  borne  in  mind  in 
considering  its  pathology  and  therapeutics.  "Were  it  possible  to  inhibit 
urination  and  bring  the  sexual  function  of  the  urethra  under  complete  con- 


CONGENITAL    DEFORMITIES    OF    THE    UEETHKA.  99 

trol,  tlie  diseases  of  this  part  would  be  of  trifling  importance  and  their  treat- 
ment very  simple.  The  diseases  of  no  other  structure  of  the  body  are 
treated  upon  such  irrational  principles  as  those  of  the  urethra,  because  of 
the  necessity  of  mechanic  disturbance  of  the  canal  at  variable  intervals  in 
the  act  of  micturition  and  the  difficulty  of  obviating  sexual  stimuli,  aside 
from  the  mechanic  dangers  of  actual  intercourse. 

The  anterior  curve  of  the  urethra  is  not  important  with  relation  to 
instrumentation,  for  it  can  be  adapted  to  almost  any  form  of  instrument. 
This  is  not  true  of  the  deep  curve,  which  is  relatively  fixed;  it  cannot  be 
said  to  be  constantly  fixed,  for  straight  instruments  can  be  introduced  into 
the  bladder.  The  fixed  urethral  curve  is  not  uniform,  varying  widely  with 
the  period  of  life  and  condition  of  the  prostate.  It  is  comparatively  short 
and  sharp  in  the  child,  longer  and  less  abrupt  in  the  adult,  the  difference 
increasing  with  age.  In  prostatic  enlargements  the  deep  curve  becomes 
elongated,  necessitating  modification  of  instruments  and  technic.  This  is 
of  great  importance  to  the  surgeon.  The  direction  and  conformation  of 
the  pendulous  urethra  is  modified  by  changes  in  the  position  of  the  penis. 
It  is  also  adaptable  to  any  form  of  instrument  for  the  urethra  or  bladder. 

The  average  normal  deep  curve,  as  established  by  Bell,  corresponds  to  a 
circle  three  and  one-fourth  inches  in  diameter,  the  proper  length  of  curve 
being  an  arc  of  such  a  circle  subtended  by  a  chord  two  and  three-fourths 
inches  in  length.  The  length  of  curve  suggested  for  instruments  by  Thomp- 
son is  generally  too  long.  The  shorter  the  beak  of  the  sounds — providing  it 
be  adapted  to  the  normal  curve — the  more  thoroughly  under  control  will  the 
instrument  be  during  insertion. 

The  author  believes  that  the  majority  of  surgeons  entertain  an  exagger- 
ated estimate  of  the  required  length  of  instruments.  As  a  result,  vesical 
and  urethral  instruments  are  usually  much  too  long,  and  consequently 
often  do  damage. 

Congenital  Deformities  of  the  Urethra. — Hypospadias  and  Epi- 
spadias.— These  comprise  the  two  conditions  which  embrace  practically  all 
of  the  congenital  deformities  of  the  urethra,  save  the  rare  cases  in  which 
diverticula  or  double  channel  exists.  These  conditions  have  quite  generally 
been  accepted  as  due  to  a  failure  of  development  in  intra-uterine  life.  The 
embryo  being  practically  laid  down  primarily  in  two  longitudinal  sections, 
which  subsequently  become"  fused  together  in  a  perfect  anatomic  entity,  it 
is  obvious  that  failure  of  fusion  at  any  particular  point  may  produce  con- 
genital deformity.  The  deformity  necessarily  varies  in  kind  according  to 
the  location  of  developmental  failure,  and  its  degree  is,  of  course,  modified 
by  the  extent  of  such  defect  in  fusion.  It  seems  logical  to  infer  that  the 
deformities  under  consideration  are  the  results  of  the  failure  of  fusion  of 
the  genital  furrow.  It  is  the  normal  fusion  of  this  furroAv  which  eventually 
differentiates  the  sexes.  A  failure  of  development  results  in  an  approxima- 
tion to  the  male  or  female  type  according  to  the  degree  to  which  embrvonic 


100 


DISEASES    OF    THE    MALE    URETHRA. 


deyelopment  lias  arrived  at  the  time  development  is  interfered  with.  The 
Yarious  forms  of  failure  of  differentiation  have  led  in  manj^  instances  to  eon- 
fusion  in  the  determination  of  sex;  the  subjects  of  hypospadias  and  epi- 
spadias,— especially  the  former, — -therefore,  are  very  closely  associated  with 
hermaphroditism  in  its  various  phases.  Failure  of  fusion  of  the  scrotum, 
associated  with  cryptorchidism,  rudimentary  development  of  the  penis,  and 
hypospadias,  represents  the  most  frequent  type  of  pseudohermaphroditism 
— the  type  that  most  often  masquerades  as  true  hermaphroditism.     As  will 


Fig.   20. — Case   of  hypospadias    (pseudohermaphroditism). 
(After  C.  A.  Wheaton.) 


be  seen  later  on,  the  subject  of  sexual  perversion  is  very  intimately  blended 
with  urethral  deformities. 

Failure  of  embryonic  development  as  the  cause  of  urethral  deformities 
has  recently  been  disputed.  Thiersch,  for  example,  and  others  have  claimed 
that  these  deformities  are  due,  not  to  imperfect  embryonic  development, 
but  to  atresia  of  the  urethra,  with  subsequent  rupture  behind  the  point  of 
obstruction.  Xumerous  arguments  have  been  advanced  by  these  investi- 
gators, dilation  of  the  ureter  and  pelvis  of  the  kidney,  such  as  is  often  found 
in  hydronephrosis,  and  the  presence  of  cicatricial  tissue  being  the  chief 
points  by  which  the  new  view  is  supported.     The  author  cannot  accept  the 


HYrOSPADIAS. 


101 


new  theory;  there  are  too  many  analogous  conditions  that  must  almost 
necessarily  develop  along  the  same  lines  as  urethral  deformities  and  which 
cannot  be  explained  upon  a  simple  mechanic  basis.  The  principal  argument 
against  the  new  theory  is  the  general  defective  development  associated  with 
urethral  deformities,  there  being  not  only  a  failure  of  physical,  but  also  of 
psychosexual  differentiation  in  a  large  proportion  of  cases.  It  is  not  neces- 
sary to  resort  to  a  mechanic  explanation  of  the  intimate  association  of  con- 


Fig.  21. — Case  of  hypospadias  with  marked  feminine  physUjiie.     Psycho- 
sexuality  normal.     (After  C.  A.  Wheaton.) 


genital  diseases  of  the  kidney  and  ureter  f,ound  coincidently  with  all 
urethral  deformities.  The  same,  aberration  and  failure  of  embryonic  de- 
velopment are  sufficiently  explanatory  in  both. 

Hypospadias. — In  this  condition  the  deficiency  of  development  is  situ- 
ated along  the  floor  of  the  urethra,  and  is  associated  with  a  defective  penile 
development  proportionate  to  the  degree  of  hypospadias.  The  urethra  may 
open  at  any  point  from  the  frenum  preputii  to  the  perineum;  the  farther 
back  the  opening,  the  greater  the  failure  of  differentiation  of  sex.     In  the 


102 


DISEASES    OF    THE    MALE    TEETHEA. 


majority  of  instances  tlie  deformity  is  slight,  the  urethra  opening  just  be- 
hJTid  or  at  the  side  of  the  frenuni.  Cases  in  which  the  opening  is  located 
posterior  to  the  peno-scrotal  angle  are  relatively  rare.  In  the  milder  yariety 
there  is,  as  a  rule,  no  great  inconvenience  resulting  from  the  condition, 
soiling  of  the  clothing  with  urine  and  sterility  being  the  princij)al  features 
of  annoyance,  these  disagreeable  results  increasing  in  degree  jyari  passu 
with  the  extent  of  the  deformity. 

Teeatmext. — In  a  large  proportion  of  instances  in  which  the  condition 
practically  consists  in  the  opening  of  the  urethra  a  short  distance  posterior 
to  its  normal  situation  in  the  glans,  hypospadias  gives  so  little  inconvenience 


Fig.  22. — Operation  for  hyi^ospadias.      (After   Duplay.) 


that  there  is  very  little  warrant  for  surgical  interference.  An  important 
practical  point,  however,  is  the  fact  that  in  the  event  of  gonorrheal  infec- 
tion the  resultant  urethritis  is  liable  to  be  very  j^rotracted  and  rebellious 
to  treatment,  the  hypospadiac  meatus,  or  pseudomeatus,  being  small  and 
perhaps  attended  by  a  pouching  of  the  urethra  anterior  to  it,  sometimes 
by  diverticula  running  either  anteriorly  or  posteriorly.  In  many  of  the 
simpler  cases,  if,  for  cosmetic  or  other  reasons,  operation  is  demanded,  a 
new  urethral  channel  may  be  made  through  the  glans  in  such  a  manner  as 
to  connect  acctu'ately  T^itli  the  urethra  at  the  site  of  the  hj'pospadiac  open- 
ing. The  new  channel  is,  with  difficulty,  however,  kept  open,  and  should 
be  made  as  large  as  practicable,  to  allow  for  subsequent  shrinkage.     The 


TREATME^TT    OF   HYPOSPADIAS. 


103 


abnormal  opening,  if  small,  may  close  spontaneously,  but,  as  a  rule,  requires 
a  plastic  operation.  In  hypospadias  of  moderate  degree — i.e.,  those  extend- 
ing only  so  far  back  as  the  peno-scrotal  angle,  or  perhaps  slightly  beyond 
it — Duplay's  operation  has  achieved  the  best  results.  It  consists  of  three 
stages: — 

1.  Straightening  the  penis  by  transverse  incision  through  the  ridge 


Fig.  23. — Case  of  simple  epispadias.      (After  C.  A.  Wlieaton.) 


uniting  the  glans  penis  to  the  hypospadiac  orifice.  The  depth  of  this  in- 
cision is  regulated  entirely  by  the  extent  of  the  deformity.  The  second  step 
of  the  operation  should  be  deferred  from  one  to  four  months  after  the  pre- 
liminary straightening  of  the  organ,  the  delay  being  governed  entirely  by 
the  extent  of  the  curvature  for  the  relief  of  which  the  first  incision  was 
made. 


104 


DISEASES    OF    THE    MALE    UEETHEA. 


2.  A  new  meatus  and  urethral  canal  is  made^  extending  from  the  canal 
to  the  hypospadiac  opening.  In  cases  in  which  the  meatus  and  urethra 
anterior  to  the  h3qDospadiac  opening  is  represented  by  a  cleft,  the  two  edges 
may  be  freshened  and  brought  together.  Where  no  cleft  exists  the  glans 
must  be  tunneled  through.  The  spongy  urethra  is  restored  as  follows:  An 
incision  is  made  longitudinally  from  the  base  of  the  glans  to  near  the  hypo- 
spadiac opening  (Fig.  22,  A:  a  to  h  and  a  to  h).  The  inner  lips  of  these 
longitudinal  incisions  are  dissected  up  for  a  short  distance,  folded  over,  and 
the  edges  united  over  a  soft  catheter.  The  outer  lips  of  the  incisions  are 
dissected  extensively  so  as  to  make  two  large  lateral  flaps;  these  are  united 
in  the  median  line  over  the  raw  surfaces  of  the  inner  flap,  which  have  al- 
ready been  united  over  the  catheter.     This  procedure  gives  a  urethra  lined 


Fig.  24.- — Dolbeau's  operation.  1.  Glans  penis.  2.  Dorsal  furrow  (rudimentary 
urethra).  3.  Orifice  of  urethra.  4-4,  5-5.  Abdominal  and  penile  flaps.  6. 
Scrotum.  7.  Superior  scrotal  incision.  S.  Inferior  scrotal  incision.  (After 
Thiersch.) 


with  cuticle  and  with  a  double-layered  cutaneous  wall.  Quilled  sutures 
should  be  used,  the  best  suture  material  being  silver  wire  or  silk-worm  gut. 

3.  The  edges  of  the  hypospadiac  opening  are  freshened  and  brought 
together,  or  otherwise  operated  as  is  usual  in  penile  fistula. 

Plastic  operations  for  hypospadias  are  often  tedious  and  require  fre- 
quent operations  to  secure  a  successful  result.  The  statistics  of  the  Uni- 
versity of  Pennsylvania  Hospital  show  that  Duplay's  operation  demands, 
on  the  average,  three  or  four  operations,  extending  over  from  six  to  eight 
months,  the  principal  trouble  being  experienced  in  the  second  stage. 

Epispadias. — Epispadias  is  rarer  than  hypospadias,  most  often  found 
in  the  female,  and  generally  associated  with  exstrophy  of  the  bladder.  It 
is  sometimes  associated  with  congenital  absence  of  the  symphysis  pubis. 


EPISPADIAS.  105 

and  is  so  often  combined  with  ectopia  vesicae  tliat  its  consideration  properly 
falls  under  .the  head  of  congenital  deformities  of  the  bladder,  in  which  con- 
nection it  will  receiye  further  discussion.  There  are  some  rare  cases  in 
which  there  is  a  simple  epispadias  without  exstrophy.  One  of  the  best  ex- 
tant illustrations  of  this  condition  is  a  case  operated  successfully  by  Wheaton. 
(Fig.  23.)  In  these  simpler  cases  the  same  operative  principles  may  be  ap- 
plied as  in  hypospadias. 

One  of  the  best  and  simplest  operations  for  simple  epispadias  is  Dol- 
beau's  modification  of  Nekton's  method.  A  quadrilateral  flap  is  first  formed 
from  the  skin  of  the  abdomen.     (Fig.  2J:.)     This  flap  should  be  about  3 


Fig.  25. — Dolbeau's  operation,  flaps  in  position.  1.  Glans  penis.  2.  Frenuni. 
3.  Prepuce.  4.  Scrotum.  5.  Scrotal  flap.  6.  Urethra.  7.  Denuded  surface 
left  after  removal  of  the  abdominal  flap.     (After  Thiersch.) 

inches  long  and  'V^  inch  wide,  its  base  corresponding  with  the  urethral 
opening.  Two  smaller  flaps  are  next  formed  from  the  penis,  one  on  either 
side  of  the  dorsal  furrow.  The  abdominal  flap  is  brought  down,  apron 
fashion,  with  the  cutaneous  side  below,  forming  the  roof  of  the  new  canal, 
and  the  edges  of  the  turned-doAvn  flap  stitched  to  the  edges  of  the  penile 
flaps,  making  a  tube  lined  by  cuticle,  with  an  external  raw  surface.  A 
semi-elliptic  flap  is  next  cut  from  the  scrotum.  This  is  dissected  up  through 
an  incision  at  its  base  and  the  penis  drawn  through  in  such  wise  that  the 
glans  projects  below  the  lower  edge  of  the  scrotal  flap,  thus  bridging  over 
the  new  urethra  with  a  la5^er  of  scrotal  tissue,  the  inner  raw  surface  of  which 
comes  in  apposition  Avith  the  outer  raw  surface  of  the  turned-down  ab- 


106 


DISEASES    OF    THE    MALE    rEETHKA. 


dominal  flap.  The  bridge  is  sutured  in  position  and  the  ra^v  surfaces  left 
in  forming  the  flaps  covered  in  as  well  as  may  be  b}'  sliding  the  skin  from 
their  edges.  The  objection  to  the  method  is  that  no  glans  canal  is  formed, 
and  there  is  no  great  improvement  in  urinary  control  aside  from  increased 


Fig.  26. — Formation  of  glans  uietlira.  A,  1-1,  2-2.  Denuded  surfaces  at  sides  of 
urethral  furrow.  B,  Cross-section  showing  depth  and  direction  of  in- 
cisions 1-1  and  2-2.     C,  Glans  urethra  completed.     (After  Thiersch.) 

facility  in  wearing  a  urinal.     Cosmetically  speaking,  however,  the  method 
is  often  very  serviceable. 

Thiersch  has  devised  a  method  of  operation  for  epispadias  that  is  held 
by  most  operators  to  be  superior  to  Dolbeau"s.  The  operation  is  divided 
into  five  steps,  viz.:     1.  The  formation  of  a  perineal  fistula  to  divert  the 


Fig.  27. — Formation  of  penile  urethi-a.     1,  Right  flap,  dissected  outward. 
2,  Left  flap,  dissected  inward.     (After  Thiersch.) 


urine.  2.  The  formation  of  a  glans  urethra.  3.  The  formation  of  a  penile 
urethra.  4.  Uniting  the  penile  and  glans  urethras.  5.  Closing  the  poste- 
rior defect. 

The  formation  of  the  perineal  fistula  is  very  simple.     A  staff  is  intro- 


TEEATMEXT    OF    EPISPADIAS. 


107 


duced  into  the  bladder  and  its  jDoint  pressed  well  down  into  the  perineum. 
The  rectum  is  guarded  by  passing  the  left  index  finger  into  the  gut  while 


'H--^... 


Fig.  28. — Flaps  sutured  in  position.  1,  Large  flap  drawn  over  to  the  left  side 
of  penis.  2,  Stitches  anchoring  inner  flap.  3,  Meatus.  4,  Defect  between 
the  new  penile  and  glans  urethras.     (After  Thiersch.) 

the  perineum  is  being  opened  upon  the  point  of  the  sound.    Drainage  should 
be  secured  by  a  soft  catheter  or  tube. 

The  second  step  of  the  operation  consists  in  converting  the  furrow  in 


Fig.  29. — Formation  of  preputial  graft.     2.  3,  Incision  through  prepuce. 
(After  Thiersch.) 


the  dorsal  surface  of  the  glans  into  a  urethra.  An  incision  ^/^  inch  in  depth 
is  made  upon  the  dorsal  surface  of  the  glans  on  each  side  of  the  furrow. 
The  incisions  should  traverse  the  whole  extent  of  the  glans  antero-poste- 


108 


DISEASES    OF    THE    MALE   UEETHEA. 


riorlv,  and  sliould  be  directed  toward  the  median  line  below  in  such  wise 
that  they  would  meet  if  continued  clear  through  the  glans.  The  included 
portion  of  glans-tissue  is  wedge-shaped  (Fig.  36,  A,  B).    The  edges  of  the 


Fig.  30. — Preputial  graft  (1)  in  position  and  (2)   sutured. 
(After  Thiersch.) 

lateral  flaps  are  denuded  and  brought  together  with  harelip-pin  sutures 
(Fig.  26,  AC). 

-    The  third  step  consists  in  forming  a  penile  urethra  by  closing  in  the 
dorsal  furrow.    An  incision  is  made  on  the  right  side  of  the  furrow  for  its 


Fig.  31. — Closure  of  posterior  urethral  defect.     Formation  of  flaps   (1,  2)   and 
suture  of  left  flap.     (After  Thiersch.) 


entire  length.  At  each  end  of  this  longitudinal  incision  a  transverse  cut  is 
made,  extending  outward  so  as  to  form  a  quadrilateral  flap  (Fig.  27,  1).  A 
second  flap  is  made  upon  the  left  side  of  the  organ  by  a  longitudinal  in- 


TEEATMENT    OF    EPISPADIAS. 


109 


cision  at  a  little  distance  from  the  edge  of  the  furrow  and  two  transverse 
incisions  extending  from  either  end  of  the  longitudinal  cut  to  the  edge  of 
the  furrow  (Fig.  37,  2).  It  will  be  seen  that  one  of  these  flaps  is  dissected 
outward  and  the  other  inward.  In  forming  the  flaps  as  much  subcutaneous 
tissue  should  be  dissected  up  as  possible.  The  edge  of  the  left  flap  is  pro- 
vided with  three  or  four  sutures,  with  a  needle  upon  each  end,  and  drawn 
beneath  the  right  flap,  the  needles  and  sutures  being  passed  through  the 
base  of  the  latter.  The  sutures  are  tied,  and.  a  second  line  of  sutures  in- 
serted on  the  left  side  in  such  a  manner  as  to  appose  as  nearly  as  possible 
the  edges  of  the  right  flap  and  the  edge  of  the  denuded  area  from  which 
the  left  flap  was  taken  (Fig.  28).  The  raw  surfaces  of  the  flaps  are  now  in 
close  apposition,  the  cutaneous  surface  of  the  left  flap  forming  the  roof  of 
the  new  penile  urethra.    Care  should  be  taken  not  to  have  too  much  tension 


Fig.  32. — Closure  of  posterior  urethral  defect.     Suture  of  left  flap. 


on  the  flaps,  else  sloughing  may  occur.  This  may  be  avoided  by  making 
them  as  thick  as  possible,  especially  at  their  bases,  and  dissecting  them  up 
freely  enough  to  avoid  the  necessity  of  drawing  them  tightly  in  order  to 
secure  apposition. 

The  fourth  step  in  the  operation  consists  in  uniting  the  penile  and 
glans  urethras.  The  edges  of  the  opening  between  the  two  portions  of  tlie 
urethra  are  first  thoroughly  denuded.  An  incision  is  next  made  in  the  pre- 
puce (Fig.  29)  and  the  glans  penis  buttoned  through  it.  The  edge  of  the 
inferior  layer  of  the  prepuce  is  now  stitched  to  the  freshened  corona  glandis, 
and  the  edge  of  the  superior  layer  to  the  penile  edge  of  the  defect  (Fig.  30). 

The  fifth  and  final  step  of  the  operation  is  the  closure  of  the  posterior 
defect.    Two  triangular  flaps  are  formed  from  the  abdominal  wall  (Fig.  31). 


110  DISEASES    OF    THE    MALE    UKETHEA. 

The  flap  on  the  patient's  left  is  somewhat  smaller  than  the  right.  The  left 
flap  is  turned  downward  so  that  its  skin-snrface  forms  a  roof  for  the  open- 
ing. The  edge  of  this  flap  is  sutured  to  the  freshened  lower  edge  of  the 
defect.  The  right  and  larger  flap  is  now  drawn  down  over  the  first  flap,  the 
raw  surfaces  of  the  two  flaps  heing  brought  in  close  apposition  and  sutured 
in  position  (Fig.  32).  After  thorough  healing  of  the  wounds  involved  in 
the  plastic  operations  the  perineal  tube  is  removed  and  the  fistula  allowed 
to  heal.  According  to  Thiersch,  considerable  time  is  necessary  between  the 
Various  stages  of  the  operation, — about  two  weeks  between  the  first  and  sec- 
ond stages,  two  weeks  between  the  second  and  third,  three  weeks  between 
the  third  and  fourth,  two  weeks  between  the  fourth  and  fifth,  and  about 
forty-two  days  for  the  fifth  and  final  stage. 

Injuries  of  the  Ueethra.  —  The  subject  of  urethral  traumatisms, 
while  strictly  surgical,  is  very  im]3ortant  to  the  general  practitioner.  He 
is  usually  first  upon  the  scene  after  injuries,  and  may  be  led  to  believe  that 
certain  cases  are  of  trifling  importance  when  they  urgently  demand  the  im- 
mediate attention  of  an  expert  surgeon.  It  is  by  no  means  serious  swelling, 
pain,  and  retention  of  urine  alone  that  require  careful  surgery.  A  knowl- 
edge of  the  ]DOSsible  immediate  dangers,  ultimate  results,  and  proper  treat- 
ment of  traumatisms  of  the  urinary  canal  is  of  the  greatest  importance  not 
only  because  of  the  immediate  gravity  of  many  cases,  but  of  the  possible 
remote,  yet  serious,  results. 

The  uretlira  may  he  contused,  lacerated,  or  cut,  either  from  internal 
or  external  violence.  Internal  injuries  are  generally  the  result  of  surgical 
operations  or  exploration.  Occasionally,  however,  the  patient  wounds  his 
urethra  by  inserting  foreign  bodies.  The  penile  urethra  is  rarely  injured 
by  external  violence,  on  account  of  its  mobility.  The  deep  urethra  is  often 
injured  by  violence  to  the  perineum,  the  bulbo-membranous  region  being 
caught  between  the  impinging  body  and  the  edge  of  the  subpubic  ligament. 
Slight  blows  may  produce  serious  injury. 

The  urethra  is  sometimes  injured  by  external  blows  with  sharp  instru- 
ments. 

Hemorrhage. 

Eetention  of  urine. 

Extravasation  of  urine. 

Sloughing. 

Possible  results  of  False  passages. 

urethral    trau-     <|     Urethritis. 

matism.  |     Pus-infection  and  abscess. 

I 

Urinary  fistula. 

Permanent  curvature  of  the  penis  of  varying  form. 

Intractable  stricture. 

Fatal  sepsis. 


rOREIGN    SUBSTANCES    JX    THE    UEETHEA.  Ill 

Treatment. — In  urethral  injuries,  however  slight,  the  clanger  of  sub- 
sequent stricture  must  be  remembered.  It  may.  be  averted  by  systematic 
sounding.  Hemorrhage  may  be  controlled  by  pressure,  ice-bags,  or  the  re- 
tained catheter.  If  the  injury  be  extensive  and  a  catheter  can  be  easily 
introduced,  it  should  be  retained  for  a  few  days,  until  danger  of  extravasa- 
tion has  passed.  Systematic  dilation  should  then  be  practiced.  If  the 
penile  urethra  be  extensively  lacerated,  a  perineal  puncture  should  be  made 
for  vesical  drainage  and  the  lacerated  tissues  should  be  stitched  in  layers 
over  a  soft  catheter  or  a  piece  of  rubber  tubing.  The  perineal  tube  may 
be  removed  at  the  end  of  a  week.    Primary  union  usually  results. 

Care  should  be  taken  in  passing  instruments  after  urethral  injuries  lest 
the  lacerated  tissues  be  penetrated  and  a  false  passage  made. 

In  deep  urethral  injuries  a  catheter  should  always  be  retained  for  a 
week  or  more,  after  which  dilation  should  be  begun.  If  it  be  difficult  to 
pass  the  catheter  or  the  injury  be  severe,  perineal  section  is  indicated.  If 
it  be  possible  to  suture  the  divided  urethra,  even  in  part,  it  should  be  done. 
The  author  is  of  opinion  that  perineal  section  is  safest  in  the  majority 
of  cases  of  injury  to  the  perineal  portion  of  the  urethra.  Should  extrava- 
sation of  urine  be  suspected  perineal  section  is  imperatively  necessary. 

In  all  urethral  injuries  strict  attention  should  be  paid  to  asepsis  and 
antisepsis.  The  most  important  point  in  urethral  traumatisms  is  the  fact 
that  stricture  of  the  canal  often  follows  injuries  so  trivial  as  to  attract 
little  or  no  attention.  Careful  after-treatment  may  prevent  this.  The 
author  desires  to  especially  emphasize  the  desirability  of  systematic  dilation 
after  all  injuries  of  the  urethra,  however  slight  they  may  appear. 

Foreign  Substances  in  the  IJrethra. — Considerable  space  would  be 
required  to  enumerate  the  substances  that  have  been  introduced  into  the 
urethra  1)y  patients  actuated  by  curiosity  or  perverted  sexuality.  Young 
lads  often  introduce  foreign  bodies,  which,  slipping  beyond  the  reach  of 
their  fingers,  produce  a  degree  of  subsequent  trouble  determined  entirely 
by  the  character,  size,  and  location  of  the  foreign  substance.  Surgeons 
sometimes  break  off  catheters  or  other  surgical  instruments  in  the  urethra. 
French  gum  catheters  are  quite  dangerous,  in  this  respect,  after  they  be- 
come old  and  brittle. 

Eetention  of  urine. 

Extravasation  of  urine. 

Hemorrhage. 

Urethritis. 

„      .        T     ,.  ,     Ulceration. 

foreign    bodies     <     -n      ,  .  ,^  ,^ 

4„  j.T,„  ,,^^4.x,^„        I     lii^ipture  ol  the  urethra. 

Sloughing. 
Abscess  and  fistula. 

Deposition  of  urinary  salts  and  resulting  calculous 
formation. 


Possible  results  of 
foreign  bodies 
in  the  urethra. 


112  DISEASES    OF    THE    MALE    rRETHRA. 

Eoreign  bodies  are  very  infrequently  met  with  in  the  female  urethra, 
the  canal  being  so  short  that  foreign  substances  rarely  lodge,  being  pushed 
onward  into  the  bladder. 

Treatment. — Simple  manipulation,  combined  with  meatotomy,  if 
necessary,  is  often  successful  in  removing  foreign  bodies.  Specially-con- 
structed urethral  forceps  are  sometimes  required.  When  these  means  fail 
the  foreign  body  should  be  pushed  on  into  the  perineal  urethra  and  a 
perineal  section  made.  The  perineal  section  should  be  made  before  the 
foreign  body  is  pushed  down,  unless  it  be  of  good  size;  small  bodies  may 
otherwise  enter  the  bladder. 

In  the  author's  opinion,  prompt  perineal  section  is  usually  much  safer 
than  prolonged  attempts  at  extraction  of  a  foreign  body  by  urethral  forceps. 
In  the  case  of  soft  bodies  it  has  been  recommended  to  insert  a  fine  needle 
into  the  urethra  from  without  and  pry  the  foreign  body  outward  toward 
the  meatus.  The  author  has  succeeded  in  one  case  of  foreign  body  in  the 
urethra — a  large  bean  that  had  become  swollen — by  ballooning  the  urethra 
anterior  to  it  with  warm  water.  The  act  of  forcible  urination  expelled  urine, 
foreign  body,  and  injected  water,  altogether.     An  excellent  plan  in  some 


Fig.  33. — Alligator  urethral  forceps. 

cases  is  to  pass  a  large  endoscopic  tube  down  into  the  foreign  body,  fix  it 
Math  the  finger  posteriorly,  and  extract  through  or  with  the  tube  by  means 
of  a  screw-tipped  probe  or  with  forceps. 

The  yarious  results  of  foreign  bodies  should  be  treated  upon  their 
merits  in  each  particular  instance.  They  do  not  demand  especial  considera- 
tion here. 

TuMOES  OF  THE  Ueethea. — The  urethra  is  occasionally  the  seat  of 
neoplasms  of  various  lands.  Since  the  advent  of  endoscopy  urethral  tumors 
have  been  found  to  be  more  frequent  than  previously  supposed.  They  vary 
in  gravity  from  inflammatory  neoplasms  to  malignant  growths. 

Inflammatory  neoplasms  are  usually  associated  with  chronic  urethritis, 
occasionall}'  with  organic  stricture.  They  consist  of  submucous  overgrowth 
of  connective  tissue  projecting  into  the  canal,  and  are  richly  supplied  with 
blood-vessels  and  covered  with  epithelium  similar  to  that  of  the  normal 
urethra.  Fungus  or  papillomatous  excrescences  sometimes  form,  being  ap- 
parently due  to  granular  urethritis.  The  vascular  supply  is  sometimes  so 
rich  that  the  growth  resembles  angioma. 

Inflammatory  urethral  growths  resemble  the  vegetations  met  with  upon 
the  external  penile  surfaces.    The  author  has  noted  several  cases  associated 


TUMOKS  OF  THE  rEETHKA.  *      113 

with  external  vegetations^,  the  urethral  growth  being  limited  to  the  fossa 
naviciilaris.  Papillomata  sometimes  occur  in  the  anterior  urethra  inde- 
pendently of  external  growths.    Distinct  mucous  polypi  have  been  observed. 

Prior  to  the  invention  of  the  endoscope  antemortem  diagnosis  of  the 
softer  varieties  of  urethral  neoplasm  was  mere  guess-work.  Urethral  tumors, 
usually  in  the  form  of  the  well-known  caruncle,  are  more  readily  recognized 
in  the  female  than  in  the  male,  because  of  the  shortness  and  dilatability  of 
the  canal. 

The  following  unique  case  of  urethral  tumor  recently  came  under  the 
author's  observation: — 

Case. — W.  H.,  aged  23,  undeilaker.  No  history  of  injuiy  or  venereal  disease. 
Has  been  an  occasional  drinker.  Has  drunk  to  excess  at  intervals,  but  does  not  in- 
dulge as  a  regular  habit.  Heredity  good.  Was  healthy  until  three  years  ago,  when 
he  began  to  suffer  from  frequent  micturition  and  pain  over  the  pubes  and  in  the 
perineum,  especially  marked  after  urination.  The  attacks  lasted  for.  a  week  or  more 
and  then  disappeared.  Recurrences  were  at  irregular  intervals  and  of  varying 
severity.  Some  six  months  since  the  symptoms  grew  worse,  and  have  progressed  in 
severity.    There  was,  at  the  time  of  examination,  in  addition  to  the  symptoms  above 


Fig.  34. — Adenomata  of  the  urethra.     Natural: size.     (Author's  case.) 

mentioned,  pain  and  burning  in  the  urethra  and  glans  penis,  with  constant  desire  to 
urinate.  The  symptoms  improA^ed  when  the  patient  was  quiet.  Constipation  was 
complained  of.  Appetite  good  and  nutrition  not  appreciably  disturbed.  Color  was 
indicative  of  excellent  general  health.  Sleep  disturbed  by  frequent  micturition.  Rec- 
tum and  anus  healthy.  The  urine  was  normal.  There  had  never  been  any  hematuria 
or  other  urinary  disturbance  nor  any  pain  in  the  region  of  the  kidneys. 

Examination  by  searcher,  sound,  and  cystoscope  showed  the  bladder  to  be  healthy. 
The  membranous  and  prostatic  portions  of  the  urethra  were  extremely  sensitive,  but 
there  was  no  obstruction  save  that  incidental  to  spasm  of  the  musculo-membranous 
region.  The  urethral  caliber  was  30  F.  Unfortunately,  the  endoscope  was  not  used. 
The  onlj^  objective  condition  discoverable,  aside  from  the  spasm  mentioned,  was 
moderate  enlargement  and  tenderness  of  the  prostate.  Other  methods  of  treatment 
having  proA'ed  ineflfectual,  perineal  section  and  dilation  of  the  vesical  neck  were  pro- 
posed, and  consented  to. 

Operation.- — The  usual  perineal  houtonniere  having  been  made,  the  vesical  neck 
was  readily  stretched  to  the  size  of  the  index  finger,  and  the  bladder  thoroughly 
explored  without  discovering  anything  abnormal.  In  exploring  the  bulbo-membranous 
region  more  critically,  a  slight  elevation  Mas  found  upon  the  urethral  floor  just  in 
front  of  the  opening  in  the  triangular  ligament  Under  manipulation,  this  was  found 
to  peel  up  under  the  finger.     By  careful  dissection,  still  \\\Vs\  the  finger,  the  slight 


114 


DISEASES    OF    THE    MALE   UEETHEA. 


elevation  was  found  to  be  part  of  a  good-sized  mass  of  tissue  occupying  chiefly  the 
right  side  of  the  bulb,  which  had  been  dilated  outward  and  backward,  forming  a 
considerable  pocket.  The  tumor  was  lobulated  to  the  feel  and  quite  friable,  a  good 
portion  of  its  bulk  breaking  down  under  the  finger  and  coming  away  piecemeal.  At 
the  posterior  portion  of  the  growth  on  the  right  side  was  a  distinct  aperture  in  the 
triangular  ligament  too  small  to  admit  the  index  finger.  The  final  attachment  of 
the  tumor  seemed  to  be  in  this  opening,  suggesting  the  origin  of  the  growth  in  this 
situation.  Recovery  with  complete  relief  of  symptoms  was  rapid.  The  perineal  wound 
was  healed  within  a  week.  The  only  fragments  of  the  tumor  of  any  size  that  it  was 
practicable  to  remove  entire  are  shown  in  Fig.  34.  These  comprised  less  than  half 
the  mass  as  outlined  by  the  finger.  The  microscopic  characters  of  the  growth,  shown 
in  Fig.  35,  verify  the  diagnosis  of  adenoma  suggested  by  the  gross  physical  features 
of  the  tissue  as  felt  by  the  finger  and  noted  in  the  specimens  removed. 

The  tumor  in  the  foregomg  case  probably  originated  in  the  right  Cow- 
per  gland.     The  absence  of  urinary  obstruction  is  remarkable.     Why  the 


ti-i^mu 


Fig.  35. — Adenoma  of  the  urethra,  a,  Normal  gland-tissue.  6,  Columnar  epi- 
thelium projecting  into  gland,  forming  papillae,  c.  Cystic  gland,  d, 
Heaped-up  epithelium,  e.  Columnar  epithelium  in  single  layer.  (Author's 
case.) 


tumor  should  have  become  flattened  in  form  and  extend  outward  and  back- 
ward rather  than  toward  the  urethral  canal  is  difficult  of  conjecture.  The 
fact  that  constant  perineal  pain  Avas  not  experienced  militates  somewhat 
against  the  assumed  origin  of  the  tumor.  Obviously  the  point  of  departure 
may  have  been  the  urethral  glands. 

Cancee  of  the  Ueethea. — This  is  usually  secondary  to  cancer  of  the 
penis,  and  requires  nr  special  consideration  here.  Cases  of  primary  cancer  of 
the  urethra  have  been  reported,  but  they  have  usually  been  erroneously  diag- 
nosed until  late.     Most  of  these  cases  have  been  located  in  the  perineum, 


CANCEE.  115 

and  rarely  even  in  these  cases  the  nrethra  may  have  been  secondarily 
diseased.  Grlinfeld  has  reported  a  case  in  which  he  diagnosed  primary 
cancer  of  the  prostatic  urethra  by  the  endoscope.  Several  cases  have  been 
reported  in  which  primary  cancer  began  in  the  anterior  nrethra.  Van 
Hook's  cases  have  already  been  mentioned. 

Symptoms.— The  symptoms  of  urethral  tumor  are  those  of  chronic 
urethritis  with  obstruction — if  the  growth  be  sufficiently  large — and  per- 
haps hemorrhage  during  micturition.  Benign  tumors  of  the  urethra  are 
usually  found  casually  when  the  surgeon  is  seeking  for  a  cause  for  a  pro- 
tracted urethral  discharge.     They  may  sometimes  be  felt  on  palpation. 

Teeatment.- — The  treatment  of  urethral  tumors  is,  briefly,  removal  by 
forceps  or  scissors  via  the  endoscope  or  urethral  speculum,  with  subsequent 
careful  cauterization  of  the  base  of  the  growth.  In  deep  tumors  perineal 
section  is  indicated.  Cancer  of  the  urethra  demands  amputation  of  the 
penis. 


CHAPTEE  IX. 

Ueethkitis  a^^d  Goxoeehea. 

Ueethritis  is  the  most  frequent  disease  of  the  male  genito-urinary 
tract,  being  relatively  infrequent  in  the  female.  It  is  usually  contracted 
during  sexual  intercourse;  so  exceptionally  is  it  otherwise  acquired  that  it 
has  been  termed  the  most  venereal  of  diseases.  The  most  common  term 
for  urethritis  is  gonorrhea.  This  is  a  misnomer:  first,  because  it  implies  a 
morbid  discharge  of  semen;  second,  because  indicating  disease  of  unvarying 
and  specific  type.  The  generic  term  urethritis  is  accurate  in  the  male,  in- 
asmuch as  it  not  only  implies  inflammation  of  the  urethra,  but  embraces 
all  its  varying  forms  irrespective  of  their  origin.  ISTeisser's  discovery  of  the 
gonococcus  has  apparently  fixed  the  generic  term  gonorrhea  in  its  applica- 
tion to  a  specific  type  of  inflammation  of  the  mucous  membranes  in  both 
the  male  and  female.  If  we  accept  the  gonococcus  as  specific  in  character, 
a  broad  line  of  clinical  differentiation  is  at  once  established  in  urethritis. 
We  are  still  compelled  to  recognize,  however,  certain  cases  in  which  the 
presence  or  absence  of  the  gonococcus  does  not  prove  or  disprove  the  venereal 
origin  of  the  disease.  This  is  especially  true  where  the  patient  has  cohabited 
frequently  with  different  females,  and  has  had  previous  infection.  Here 
the  recent  attack  may  have  been  due  to  gonococcic  autoinfection  from  a 
focus  left  by  a  previous  attack  of  gonorrhea.  In  other  instances  the  patient 
has  a  non-gonococcic  discharge,  and  we  are  asked  to  decide  as  to  its  speci- 
ficity. Here  we  must  acknowledge  that  the  gonococci  may  possibly  have 
been  present  originally,  but  have  disappeared.  Practically,  therefore,  we  are 
often  in  essentially  the  same  position  as  before  the  discovery  of  the  gono- 
coccus. Especially  is  this  true  from  a  forensic  stand-point.  The  sources  of 
error  in  diagnosis  are  so  numerous  that  it  is  hardly  ever  safe  to  pronounce  a 
case  of  urethritis  specific  in  origin,  whether  gonococci  be  present  or  not,  save 
where  the  patient  can  be  proved  to  have  been  perfectly  healthy  before  the 
urethritis  developed,  or  to  have  had  intercourse  with  a  woman  suffering 
from  gonorrhea — proved  by  microscopic  examination  of  her  vaginal  secre- 
tions— or  to  have  a  clear  history  of  a  more  or  less  recent  attack  of  gonorrhea. 
This  caution  is  particularly  necessary  in  passing  an  opinion  in  the  case  of 
a  married  person.  In  any  case,  culture  and  inoculation  tests  are  necessary 
for  a  decision. 

The  discovery  of  the  gonococcus  has  not  changed  the  views  of  the 
author  regarding  the  origin  of  gonorrhea  and  its  congeners.  This  class  of 
affections,  in  common  with  chancroid,  may  still  be  classed  as  filth-diseases 
originating  de  novo  in  the  female.  The  author  believes  that  germ-infection, 
of  one  kind  or  another,  is  the  fons  et  origo  in  the  majority  of  cases  of 

(116) 


EVOLUTION  OF  THE  GONOCOCCUS.  117 

urethritis.  It  is  not  probable,  however,  that  the  germs  producing  such  in- 
fection are  always  and  invariably  the  same.  Gonorrhea  is  as  old  as  the 
human  race,  but  that  the  gonocoecus  originally  resulted  from  a  special  act 
of  creation  seems  incomprehensible.  The  development  of  the  gonocoecus 
— and,  indeed,  of  all  germs  capable  of  producing  infection — has  probably 
been  along  evolutionary  lines.  We  cannot  accept  the  spontaneous  genera- 
tion of  germs  of  either  indeterminate  or  specific  type,  neither  can  we  dis- 
prove its  possibility.  The  possible  transformation  of  innocuous  germs  by 
adaptation  to  environment  into  germs  of  a  specifically-pathogenic  character 
is,  hoAvever,  scientifically  plausible  enough.  The  female  generative  ap- 
paratus constitutes  a  most  favorable  environment  for  the  development  of 
^erms  and  the  acquirement  of  pathogenic  properties  by  them.  Protection 
from  air  and  light  and  the  presence  of  heat,  moisture,  and  decomposable 
secretions  of  various  kinds  constitute  conditions  highly  favorable  to  bac- 
terial evolution.  Pathologic  discharges  and  exposure  to  local  irritation  con- 
stitute an  additional  and  important  factor.  In  uncleanly  women  vaginal 
discharges,  as  well  as  both  pathologic  and  physiologic  discharges  from  the 
male,  are  allowed  to  accumulate  and  undergo  decomposition.  The  semen 
is  a  highly  complex  organic  substance,  the  decomposition  of  which  in  all 
probability  results  in  the  development  of  highly-irritating  toxins. 

When  the  author  uses  the  term  de  novo  as  applied  to  gonorrhea,  and 
later  to  chancroid,  it  is  with  the  belief  that  both  are  germ  diseases,  and 
that  consequently  their  spontaneous  generation,  in  the  sense  of  the  develop- 
ment of  their  germs  de  novo,  is  improbable.  The  perfected  germs  of  these 
diseases  represent  the  acme  of  spontaneous  cultivation  of  germs  that  were 
primarily  quite  different,  pathologically  at  least,  from  the  final  product. 
Evolutionary  changes,  and  especially  differentiation  of  biologic  and  patho- 
genetic properties  in  germs,  must  be  admitted,  for  necessarily  the  same  laws 
apply  to  the  parasite  as  to  the  host.  It  is  very  interesting  to  the  author 
to  note  that  the  views  he  expressed  some  years  ago  upon  this  subject  in 
an  article  entitled  "The  Evolution  of  the  Local  Venereal  Diseases"  are 
being  daily  substantiated  by  practical  results  obtained  in  the  laboratory.  A 
recent  case  coming  under  the  author's  observation  appears  to  be  an  illus- 
tration of  the  fact  that  the  germ  of  gonorrhea  is  capable  of  transformation. 

Case. — The  case  was  that  of  a  young  man  troubled  with  posterior  urethritis  and 
stricture  for  nearly  two  years.  From  time  to  time  his  semen  had  been  examined  by 
competent  microscopists  and  said  to  contain  gonoeocci.  Several  months  after  the 
author  had  performed  a  urethrotomy  the  patient's  semen  was  examined,  and  found 
to  contain  -germs  strongly  resembling  the  gonocoecus.  Closer  study,  however,  showed 
that  they  were  slightly  rod-shaped,  although  typically  paired,  like  the  diplococcus  of 
gonorrhcea.  Cultures  and  experimental  inoculations  proved  the  microbe  to  be  patho- 
logically inert,  and  the  patient  was  assured  that  he  might  marry  with  safety:  a  point 
■of  great  importance  to  him,  as  he  had  been  contemplating  matrimony. 

Did  we  not  have  here  an  illustration  of  spontaneous  alteration  in  the 


118  UKETHKITIS    AND    GONOEEHEA. 

physical  and  pathogenic  properties  of  the  gonococcus?  The  case  is  certainly 
suggestive  along  the  lines  mentioned.  It  is  of  such  practical  importance  that 
the  author  believes  that  test-cultures  and  inoculations  should  be  made  in 
prolonged  cases  in  which  the  presence  or  absence  of  the  gonococcus  is  to 
be  accepted  as  the  criterion  of  cure  or  of  the  safety  of  matrimony. 

Whether  or  not  the  gonococcus  be  accepted  as  the  unvarying  cause  of 
a  specific  type  of  urethritis,  the  fact  remains  that  the  environmental  con- 
ditions that  have  been  mentioned  are  the  point  of  departure  of  germ- 
evolution,  the  products  of  which  are  infectious  and  capable  of  producing 
mucous  inflammation  of  varying  grades  of  severity,  ranging  from  simple 
urethritis  to  virulent  gonococcic  inflammation.  Precisely  what  germ  is  the 
progenitor  of  the  gonococcus  in  the  process  of  evolution  would  be  difficult 
to  determine,  but  the  difference  between  the  specific  microbe  and  certain 
germs  that  are  normally  present  in  the  male  urethra  and  also  in  the  vagina 
is  not  very  great.  The  dissimilarity  between  the  gonococcus  and  pus-mi- 
crobe is  not  marked;  the  transformation  of  the  one  into  the  other  under 
favorable  circumstances  of  environment  is  perhaps  possible.  That  we  are 
unable  to  compel  germs  to  undergo  this  process  of  evolution  is  not  a  valid 
argument  against  the  theory — of  which  more  anon. 

Varieties  or  Ueetheitis. — ^Inflammation  of  the  urethra  may  be 
divided  for  description  as  follows: — 

r  Bacteric. 

r  J  Toxic. 

(a)  bimpie {   ^,, 

I       ^  ^  }   Chemic. 

Acute  and  chronic <>  [Traumatic. 

C  Gonococcic. 


(5)  Specific <!  Chancroidic. 

^  '  [  Syphilitic. 


SIMPLE   UEETHEITIS. 

Simple  urethritis  is  a  rather  omnibus-like  term,  because  of  the  large 
number  of  causes  upon  which  it  may  depend. 

Etiology. — Predisposing  Causes. — 1.  Diathetic  conditions.  2.  Chronic 
urethral  disease.  3.  Morbid  states  of  the  urine.  4.  Sexual  abuses.  5.  Die- 
tetic excesses  and  irregularities.     6.  Alcoholism. 

Any  condition  of  the  system  giving  rise  to  irritability  of  the  mucous 
membranes  predisposes  to  inflammation.  Possibly  this  argument  cannot  be 
applied  with  equal  pertinency  to  all  mucous  membranes,  but  it  certainly 
applies  quite  forcibly  to  the  urethra.  This  is  especially  true  of  such  dia- 
thetic conditions  as  rheumatism  and  gout,  in  which  the  urine  is  likely  to 
be  loaded  with  the  products  of  retrograde  tissue-metamorphosis:  products 
that  may  be  both  mechanically  and  chemically  irritating.  Lithemia  and 
O'xalemia  are  especially  potent  in  this  direction,  producing,  as  they  do,  their 


ETIOLOGY    OF    SIMPLE    UEETHEITIS.  119 

corresponding  conditions  of  perturbation  of  tire  composition  of  the  urine: 
namely,  lithuria  and  oxaluria.  The  urine  in  lithemia  is  not  only  likely  to 
be  made  heavy  and  concentrated  by  its  disproportionate  amount  of  solids, 
but  the  uric-acid  crystals  present  are  exceedingly  irritating  to  the  mucous 
membranes  of  the  genito-urinary  tract.  There  is  no  question  but  that 
lithuria  is  responsible  for  certain  catarrhal  conditions  of  the  ureters  and 
renal  pelves.  This  catarrh  is  not  so  evident  in  the  urethra;  yet  the  mucous 
membrane,  because  of  the  irritating  urine,  is  in  a  very  sensitive  state.  This 
predisposes  to  infection  and  inflammation.  Irritability  of  nerve-supply — 
which  implies  irritability  of  the  tissues  themselves — is  also  an  important 
factor  in  the  gouty  and  rheumatic  diathesis.  Associated  with  the  gouty 
diathesis  are  dietetic  indiscretions  and  indulgence  in  alcohol. 

The  author  is  of  opinion  that  gout  and  rheumatism  are  more  inti- 
mately associated  with  urethritis  than  is  ordinarily  supposed.  Either  or 
both  may  be  a  powerful  factor  in  cases  in  which  the  exciting  cause  is 
indubitable  specific  infection.  This  is  often  a  useful  guide  in  treatment. 
By  taking  this  factor  into  consideration  stubborn  cases  may  often  be  con- 
trolled. The  rheumatic  and  gouty  diatheses  are  of  especial  importance  in 
inflammations  of  mucous  membranes.  They  are  not  so  important  in  regard 
to  the  lower  portion  of  the  genito-urinary  tract,  and  especially  of  the 
urethra,  as  to  the  throat,  but  the  same  pathologic  principles  that  govern 
the  relation  of  rheumatism  to  acute  or  chronic  inflammation  affecting  other 
mucous  membranes  pertinently  apply  to  urethral  disease. 

As  with  all  other  organs,  excessive  use  predisposes  to  inflammation.  As 
regards  the  urethra,  sexual  excesses  and  masturbation  cause  much  mechanic 
disturbance,  glandular  hyperactivity  with  excessive  secretion  of  mucus, 
and  possibly  slight  traumatisms.  These  various  factors  cause  a  catarrhal 
state  of  the  mucous  membrane  that  affords  excellent  soil  for  microbial  action 
and  enhances  irritation.  Unrest  is  of  far  greater  importance  as  a  predis- 
posing cause  of  urethritis  than  is  usually  accorded  it.  The  majority  of 
patients  do  not  seem  to  understand  that  overstrain  of  the  sexual  apparatus 
is  possible,  and  the  physician  oftentimes  seems  equally  ignorant.  If  not 
ignorant,  he  is  at  least  frequently  derelict  in  his  duties  in  this  particular. 

The  most  important  predisposing  cause  of  simple  urethritis  is  chronic 
disease  of  the  genito-urinary  tract,  whatever  its  origin  may  have  been.  Most 
cases  of  simple  urethritis  are  due  to  the  effects  of  sexual,  alcoholic,  or 
dietetic  excesses  upon  a  urethra  already  damaged,  in  which  the  products  of 
microbial  action,  especially  the  products  of  simple  decomposition,  exist. 
This  bears  pertinently  upon  cases  of  suspeeted  gonorrhea  in  which  the  virtue 
and  probity  of  one  or  both  parties  to  the  venereal  act  may  be  questioned. 

Exciting  Causes. — 1.  Trauma.  2.  Bacteria  (non-specific).  3.  Toxins. 
4.  Chemic  irritation".  5.  Sexual  strain.  It  is  unnecessary  to  expatiate  ex- 
haustively upon  traumatism  in  the  etiology  of  urethritis.  It  should  be 
remembered,  however,  that  traumatism  in  a  perfectly  healthy  and  approxi- 


120  UEETHKITIS    AND    GONOEEHEA. 

mately  aseptic  urethra  may  be  followed  by  little  or  no  inflammation.  In 
the  presence  of  some  latent  condition  of  disease — i.e.,  a  chronic  source  of 
infection — traumatism  bears  a  very  important  relation  to  acute  urethritis. 
A  very  pertinent  illustration  of  this  is  the  results  of  operations  or  instru- 
mentation where  stricture  or  congested  and  granular  patches  of  urethral 
mucous  membrane  exist. 

In  considering  the  relation  of  bacterial  infection  to  simple  urethritis 
it  is  well  to  remember  that  various  bacteria  and  their  products  may  pro- 
duce irritation  and  inflammation  of  mucous  membranes.  The  pus-microbe 
or  its  derivatives,  and  possibly  the  ordinary  germs  of  decomposition,  may, 
per  se  or  by  the  action  of  their  products,  cause  urethritis.  The  relation 
of  the  bacterium  coli  commune  to  genito-urinary  pathology  has  already  been 
discussed.  It  is  probable  that  the  line  of  demarkation  between  the  pus- 
microbe  and  the  colon  bacillus  would  be  very  difficult  to  demonstrate.  A 
suggestive  fact  is  that  the  secretions  from  urethral  disease,  originally  of  gono- 
coccic  origin,  but  from  which  all  specific  characters  have  disappeared  (as  in 
certain  cases  of  chronic  urethritis,  folliculitis,  and  prostatitis,  and  in  certain 
inflammations  of  the  female  genito-urinary  tract),  are  capable  of  producing 
inflammation  of  the  male  urethra.  That  the  toxins  evolved  by  microbic 
action  may  cause  urethritis  is  almost  certain.  Any  chemic  irritant  may  pro- 
duce urethritis,  which  sometimes  assumes  a  severe  type.  The  experiment 
of  Swediaur  with  aqua  ammonia  will  be  remembered  in  this  connection. 

In  discussing  the  exciting  causes  of  simple  urethritis  it  is  necessary 
to  correct  the  fallacious  notion  that  normal  secretions  in  the  female  are 
capable  of  exciting  urethritis  in  the  male.  It  is  nothing  unusual  for  the 
apology  to  be  offered  that  the  affected  man  has  had  intercourse  with  a  woman 
just  before,  after,  or  during  her  menses.  The  fallacious  belief  that  the 
menstrual  discharge  may  cause  urethritis  is  as  old  as  the  Bible,  as  will  be 
noted  by  a  perusal  of  the  fifteenth  chapter  of  Leviticus.  The  Jewish  tradi- 
tion that  the  female  is  unclean  for  a  time  after  the  menstrual  epoch  is 
probably  based  upon  this  common,  but  erroneously  applied,  cljnical  obser- 
vation. Menstrual  fluid — unless  decomposed  or  mixed  with  the  products  of 
bacterial  evolution,  whether  the  germs  be  autogenetie  or  heterogenetic  is  in- 
consequential— will  not  cause  urethritis.  Apparent  contradictions  are  due 
either  to  the  autogenesis  of  urethritis  in  a  previously  damaged  urethra,  or 
to  the  bringing  down  of  the  products  of  an  old  infection  into  the  vagina  by 
the  menstrual  secretion.  Menstrual .  fluid  has  been  accepted  as  a  cause  of 
urethritis,  the  water-closet  theory  has  been  repudiated,  but  the  author  be- 
lieves the  latter  has  a  basis  of  probability,  while  the  former  is  positively 
absurd.  The  "strain"  theory  of  the  origin  of  urethritis  is  very  popular,  but 
the  most  fallacious  of  alj.  Sexual  excess  alone  does  not  produce  the  disease. 
Sexual  excess  plus  a  diseased  urethra,  however,  occupies  a  very  important 
place  among  the  exciting  causes  of  urethritis.  As  a  predisposing  factor,  on 
the  other  hand,  sexual  excess  is  all-important. 


ETIOLOGY    OF    GONOKRHEA.  131 

GONOCOCCIC    OR   SPECIFIC    URETHRITIS. 

Predisposing  Causes. — These  are  the  same  as  for  simple  urethritis. 
Alcoholic  indulgence  as  a  predisposing  factor  in  specific  urethritis  demands 
special  consideration.  Promiscuous  exposure  to  infection  is  usually  asso- 
ciated with  the  free  use  of  stimulants.  Men  who  habitually  cohabit  with 
prostitutes  often  escape  infection,  save  when  the  exposure  is  accompanied 
or  followed  by  a  prolonged  drinking-bout.  A  careless  genital  toilet  is,  of 
course,  to  be  considered  here. 

Exciting  Causes. — The  author  will  not  discuss  here  the  various  argu- 
ments relative  to  the  specificity  of  the  gonococcus.  It  is  sufficient  to  say 
that  certain  types  of  virulent  urethritis  are  characterized  by  the  presence 
of  a  germ  of  peculiar  character, — the  gonococcus, — which  microbe  is  prob- 
ably the  cause  of  the  disease.  All  argument  aside,  it  has  been  conclusively 
shown  that  this  microbe  will  produce  in  a  healthy  mucous  membrane  an 
inflammation  similar  to  that  from  which  the  secretion  that  contained  it 
was  originally  derived. 

Apropos  of  the  method  of  contagion  in  gonorrhea,  considerable  illogical 
reasoning  has  been  indulged  in  regarding  the  possibility  of  infection  in  an 
innocent  manner.  Syphilis  insontium  is  well  recognized;  but  whenever  an 
individual  with  gonorrhea  gives  a  history  of  unknown  or  innocent  source 
of  infection,  the  history  is  treated  with  lofty  disdain  and  contempt  born 
of  a  profound  knowledge  of  human  nature — particularly  as  manifested  in 
venereal  diseases.  The  author  believes  that,  theoretically  at  least,  gonorrhea 
is  more  likely  to  be  contracted  innocently  than  syphilis.  Limitation  of  inno- 
cent infection  is  due  to  the  fact  that  the  structures  susceptible  to  gonorrhea 
are  of  comparatively  small  area  and  relatively  inaccessible,  whereas  in  the 
ease  of  syphilis  any  abraded  surface  serves  as  a  port  of  entry  for  the  germ. 
Given,  however,  the  contact  of  the  mucous  membrane  with  the  gonococcus, 
infection  occurs  much  more  readily  than  in  syphilis,  which  requires  an 
abrasion  as  the  essential  requisite  for  infection.  Admitting  that  gonorrhea 
depends  upon  a  very  virulent  germ,,  or  even  laying  the  germ-theory  aside 
for  the  moment  and  accepting  the  broad  proposition  that  gonorrhea  affords 
a  secretion  which  is  extremely  virulent,  it  only  remains  to  show  that  facilities 
for  the  innocent  conveyance  of  the  disease  are  frequent  in  order  to  sub- 
stantiate the  proposition  that  gonorrhea  may  possibly  be  contracted  inno- 
cently. 

The  water-closet  theory  of  the  origin  of  gonorrhea  has  received  much 
ridicule,  yet  the  author  believes  that  if  logically  considered,  the  theory  will 
not  appear  quite  so  absurd  as  at  first  sight.  It  is  a  practical  impossibility 
for  individuals  with  gonorrhea  to  use  the  public  closets  found  in  saloons 
and  hotels  without  depositing  more  or  less  of  the  virulent  discharge.  The 
meatus  is  rubbed  over  the  closet-seat  so  as  to  deposit  more  or  less  secretion, 
unless  the  patient  be  unusually  careful.    The  next  person  using  the  closet, 


123  UEETHEITIS    AXD    GOXOEEHEA. 

unless  extreinel}^  cautious,  brings  Ms  meatus  urinarius  in  contact  with  the 
infected  surface.  Is  the  belief  that  gonorrheal  infection  may  occasionally 
occur  in  this  manuer  illogical?  We  are  too  prone  to  question  the  patient's 
veracity.  Eiclicule  is  hardly  a  safe  argument  in  a  question  that  can  be 
reasoned  upon  as  logically  as  other  infections.  This  is  important  from  a 
medico-legal  stand-point.  Expert  testimony  to  the  effect  that  any  indi- 
vidual might  not  possibly  have  contracted  gonorrhea  in  the  innocent  manner 
above  described  must  certainly  depart  from  the  ordinary  rules  of  logic. 
However  profound  his  knowledge  of  infection  in  other  directions,  the  expert 
so  testifying  must  necessarily  manifest  the  densest  ignorance  of  sound 
pathologic  and  bacteriologic  principles.  The  same  argument  is  pertinent, 
although  perhaps  not  equally  so,  as  applied  to  possible  innocent  infection 
of  the  female.  The  author  is  Avell  aware  that  this  statement  is  likely  to  be 
received  with  derision,  but,  as  already  stated,  ridicule  upon  a  question  so 
open  to  logical  reasoning  as  that  under  consideration  is  hardly  worthy  of 
respect.  The  possible  forensic  application  of  the  authors  opinion  has  re- 
ceived due  consideration,  but  has  in  nowise  shaken  his  convictions. 

Accepting  the  gonococcus  as  the  most  definite  etiologic  factor  thus  far 
determined  in  virulent  urethritis,  it  becomes  necessary  to  consider  its  char- 
acteristics. During  the  last  quarter  of  a  century  several  authors  had  claimed 
to  have  discovered  the  germ  or  organism  upon  which  the  disease  depends, 
but  none  of  their  views  had  been  generally  accepted  by  the  profession  until 
the  advent  of  the  now  most  prominent  authority  upon  the  microscopic 
study  of  urethritis,  jSTeisser,  of  Breslau,  who  asserted  in  1879  that  he  had 
discovered  the  specific  microbe  of  gonorrhea,  which  he  termed  the  gono- 
coccus. Numerous  European  bacteriologists  soon  published  confirmatory 
reports,  and  during  the  last  few  years  many  competent  investigators  have 
indorsed  the  views  of  Neisser.  At  the  present  time  the  profession  has  quite 
generally  accepted  the  specificity  of  the  gonococcus.  The  detection  of  the 
alleged  specific  germ  under  the  microscope  was  first  made  possible  by  com- 
plicated processes  of  staining.  A  comparatively-simple  process  has  since 
been  found  efficient:  A  drop  of  the  suspected  pus  is  pressed  between  two 
glass  slides  and  allowed  to  dry  in  the  air.  A  drop  of  solution  of  methyl- 
blue  in  anilin-Avater  is  now  placed  upon  it  for  a  moment  and  then  removed 
by  a  stream  from  a  wash-bottle.  A  few  drops  of  Gram's  iodo-iodid  liquid 
is  then  poured  on  and  allowed  to  remain  for  several  minutes;  this  fixes 
the  color  of  micro-organisms  in  general.  Gram's  liquid  is  now  washed  off, 
and,  while  the  specimen  is  still  wet,  a  cover-glass  is  placed  upon  it  and  it 
is  examined  with  an  oil-immersion  lens.  If  micro-organisms  resembling 
the  gonococcus  are  found,  they  are  tested  by  decolorization.  The  cover- 
glass  is  removed,  and  the  specimen  treated  with  absolute  alcohol  until  the 
color  is  as  completely  removed  as  possible.  The  cover-glass  is  replaced  and 
the  specimen  examined,  when,  according  to  some,  all  the  gonococci  will 
have  disappeared:  all  the  other  organisms,  however,  being  distinctly  visible. 


ETIOLOGY    OF    GOXOEEHEA.  123 

As  already  stated,  high  authority  claims  that  culture  experiments  are  neces- 
sary to  positive  recognition  of  the  gonococcus.  It  is  usually  located  upon 
the  surface  of  the  pus-corpuscle;  more  rarely  upon  the  surface  of  the 
epithelium.  It  is  sometimes  incorporated  with  the  corpuscle,  replacing  its 
nucleus.  The  microbe  is  spherical  when  single;  in  some  instances  two  of 
them  unite  together  in  a  sort  of  biscuit  or  coffee-bean  shape.  They  are 
usually  found  in  colonies  of  ten  to  twenty  or  more.  For  practical  purposes 
a  method  of  examination  of  suspected  fluids  even  simpler  than  the  fore- 
going is  efficient.  A  drop  of  pus  placed  between  two  cover-glasses,  may  be 
spread  into  a  thin  layer  by  sliding  the  two  apart.  One  glass  is  then  thor- 
oughly dried  by  passing  it  rapidly  through  the  flame  of  a  spirit-lamp.  It  i£ 
next  dipped  in  a  solution  of  methyl-blue,  the  superfluous  coloring  matter 


-w.<^..  -^smi.    mm 


3    « 


Fig.  36. — Gonococci  in  urethral  pus. 

being  Avashed  off  by  a  stream  of  cold  water.  Finallj^  it  should  be  mounted 
in  Canada  balsam.  A  twelfth  oil-immersion  objective  gives  the  best  results. 
Neisser  has  laid  especial  stress  upon  the  obvious  tendency  of  gono- 
cocci to  arrange  themselves  in  pairs.  Being  a  diplococcus,  he  claims,  dis- 
tinguishes the  gonococcus  from  the  urethrococcus,  which  is  found  singly 
or  in  irregular  clumps.  He  also  says  that  the  gonococci  are  found  in  or 
upon  the  pus-corpuscle,  never  outside  of  it.  An  important  possible  source 
of  fallacy  has  already  been  suggested.  It  is  by  no  means  improbable  that 
the  urethrococcus  may  undergo  modification  by  a  virulent  inflammatory 
process,  as  a  consequence  of  which  it  tends  to  arrange  itself  somewhat 
differently  and  to  invade  the  pus-corpuscles.  This  is  certainly  consistent 
with  the  evolutionary  theory.  Taken  singly,  the  urethrococcus  and  gono- 
coccus are  identical  in  appearance.  At  the  present  time,  however,  the 
gonococcus  is  universally  recognized  as  a  diplococcus. 


12-i  UEETHKITIS    AXD    GONOERHEA. 

AproiDOs  of  the  specificity  of  the  gonococciis  and  its  possible  derivation 
from  the  iirethrococcus,  the  statements  made  b}^  a  recent  text-book  on  gen- 
ito-urinary  diseases  is  instructive,  and — as  the  author  reviews  the  assaults 
that  have  been  made  upon  his  views  of  the  evolution  of  gonorrhea  and  its 
congeners — somewhat  edifying.  In  this  recent  and  most  admirable  work 
will  be  found  the  following: — 

"That  the  gonococcus  is  the  specific  organism  of  gonorrhea  can  he  con- 
sidered as  absolutely  established.  .  .  .A  weak  point  in  the  evidence  is 
that  micro-organisms  are  found  in  the  healthy  urethra  ichich  exactly  resemble  ■ 
in  size,  form,  grouping,  and  color-reactions  the  gonococcus.  It  is  stated  that 
these  various  forms  can  be  readily  distinguished  by  means  of  culture;  but 
this  requires  so  much  time  and  sTxill  that  it  can  be  carried  out  only  by  the 
bacteriologist;  hence  it  is  not  practically  useful.  .  .  .  The  gonococcus  is 
distinguished  by  its  shape,  grouping,  position,  color-reaction,  and  growth  on 
artificial  media."'^ 

There  is  a  looseness  of  statement  in  the  foregoing  that  does  not  com- 
port with  the  pro230sition  that  the  gonococcus  is  "absolutely  established" 
as  the  specific  organism  of  gonorrhea,  and  which  is  hardly  scientific.  In- 
deed, it  savors  a  little  of  an  Irish  bull.  After  informing  us  that  we  cannot 
distinguish  the  gonococcus  in  any  practical  way,  the  authors  proceed  to 
tell  us  that  it  can  be  determined  only  by  cultivation  by  elaborate  methods 
in  the  hands  of  bacteriologie  specialists.  They  then  gravely  inform  us  that 
it  can  be  distinguished  by  the  characteristics  which  it  possesses  in  com- 
mon with  urethrococci  and  their  congeners,  plus  the  method  which  is 
onl}'  practicable  at  the  hands  of  the  laboratory  expert.  Diagnoses  of  gono- 
cocci  are  being  made  daily,  hot  only  by  microscopists  of  ordinary  skill,  but 
by  laboratory  experts,  yet  the  author  ventures  to  say  that  only  in  the 
rarest  instances  are  cultures  and  inoculations  made.  Are  such  diagnoses 
fallacious?  The  author  has  always  been  suspicious  of  their  reliability,  and 
is  interested  to  note  that,  according  to  even  those  who  consider  the  spec- 
ificity of  the  gonococcus  as  "absolutely  established,"  the  germ  has  as  yet 
practically  no  standing  in  court,  as  will  be  found  the  first  time  an  attempt 
is  made  to  back  up  expert  testimony  with  the  authority  from  which  quota- 
tion has  been  made.  The  opinions  of  such  undeniably  eminent  author- 
ities serve  to  strengthen  the  authors  views  that  the  specific  microbe  of 
gonorrhea  is  a  derivative  of  some  primarily  innocuous  germ  and  a  purely 
evolutionary  product.  And,  further,  he  is  of  opinion  that  the  battle  be- 
tween clinic  and  laboratory  is  by  no  means  finished,  nor  the  views  suggested 
by  each  reconciled. 

The  relative  frequency  and  severity  of  gonorrhea  in  the  negro  has 
been  the  subject  of  some  discussion.  It  has  been  claimed  that  the  black 
race  is  more  susceptible  than  the  white.     This  comports  with  the  evolu- 


White  and  Martin.     (Italics  the  author's.) 


MOEBID    ANATOilY    OF    UEETHRITIS.  125 

tionary  theory.  G-onorrhea,  like  some  other  contagious  diseases,  is  essen- 
tially a  disease  of  civilization.  The  more  ^jrimitive  the  race,  the  greater 
its  susceptibility  to  such  diseases  and  the  more  severe  their  ravages.  To 
be  sure,  there  are  certain  special  influences  at  work  in  the  American  negro 
which  may  explain,  to  a  certain  extent,  the  susceptibility  to  gonorrhea 
that  clinical  evidence  seems  to  prove  in  him.  The  personal  uncleanliness 
and  relatively  low  moral  standard  of  the  negro  must  necessarily  be  impor- 
tant factors. 

The  statement  has  been  made  that  negroes  are  less  liable  to  stricture 
than  whites.  It  has  been  estimated  that  in  the  negro  only  5  per  cent,  of 
cases  of  gonorrhea  result  in  stricture,  the  proportion  among  whites  being 
16  Vs  per  cent. — this  notwithstanding  the  fact  that  gonorrhea  is  four  times 
as  frequent  in  the  former  than  in  the  latter.  The  author's  experience  with 
stricture  in  the  negro  has  been  somewhat  limited,  but  the  cases  observed 
have  been  mostly  of  a  severe  type. 

MoEBiD  x^NATOMY. — Inasmuch  as  the  anatomic  features  of  specific  and 
simple  urethritis  differ  in  degree  only,  the  morbid  anatomy  of  the  disease  in 
general  may  be  properly  taken  up  at  this  point.  The  infection  of  urethritis 
is  generally  supposed  to  begin  at  the  meatus.  Milton  has  remarked  the  ap- 
parent contradiction  of  urethral  chancre  and  chancroid.  He  believes  that 
in  such  cases  the  virus  is  deposited  at  the  meatus,  subsequently  diffusing 
until  it  meets  with  a  susceptible  area  of  mucous  membrane.  It  is  a  question 
whether  morbid  secretions  may  not  be  drawn  into  the  urethra  during  coition. 
The  author  believes  they  may  be.  A  certain  amount  of  aspiration  is  pro- 
duced in  the  urethra  during  the  venereal  orgasm,  sufficient  at  least  to  draw 
secretions  from  the  vagina  into  the  urethra.  The  alternate  contraction  and 
relaxation  of  the  deep  perineal  muscles  incidental  to  the  efforts  of  the  ure- 
thra to  clear  itself  of  semen  must  necessarily  produce  more  or  less  suction 
at  the  meatus.  It  is  the  author's  impression  that  gonorrhea  often  begins  in 
the  fossa  navicularis, — perhaps  including  the  mucous  membrane  even 
farther  back, — rather  than  at  the  meatus  proper. 

The  extent  of  urethra  finally  involved  varies.  The  inflammation  is 
usually  most  marked  anteriorly,  but  in  severe  cases  almost  always  involves 
the  entire  canal  down  to  the  bulbo-membranOus  junction,  in  many  cases 
extending  even  to  the  posterior  urethra.  The  entire  mucous  membrane 
from  meatus  to  bladder  may  be  infected.  In  very  mild  forms  of  urethritis 
the  pathologic  changes  consist  of  slight  hyperemia  with  attendant  red- 
dening and  hypersecretion.  In  the  majority  of  so-called  simple  cases,  how- 
ever, there  are  chronic  changes  in  the  canal  due  to  a  former  severe  ure- 
thritis. The  pathologic  anatomy  of  simple  acute  urethritis  and  that  of 
chronic  urethritis  is,  therefore,  usually  identic.  In  simple  acute  or  sub- 
acute urethritis  ingrafted  on  chronic  inflammation,  the  localization  of  the 
chronic  process  with  perhaps  stricture  or  abraded,  granular,  and  congested 
patches,  is  due  to  several  causes:    1.   The  relative  inelasticity  of  the  portion 


126  UEETHRITIS   AXD    GOXOEEHEA. 

of  the  urethra  involved.  This  produces  friction  during  micturition,  with 
consequent  localization  of  inflammation.  2.  Dilation  and  severe  inflam- 
mation of  mucous  follicles.  3.  Injmy  by  instruments,  the  long-nozzled 
syringe  being  the  most  frequent  cause.  4.  Spontaneous  or  traumatic 
yielding  of  the  corpus  spongiosum  in  chordee.  5.  Slight  thickening  of 
the  urethra  due  to  old-time  traumatism.  6.  Posterior  urethral  infection 
— i.e.,  follicular  ■prostatitis — occurring  in  the  course  of  acute  gonorrhea 
and  inevitably  becoming  chronic.  More  or  less  enlargement  of  the  organ 
is  found,  together  with  a  varying  degree  of  interstitial  thickening  and 
chronic  inflammation  in  the  prostatic  ducts  and  follicles.  7.  Seminal  ve- 
siculitis associated  with  a  varying  degree  of  prostatic  involvement. 

In  the  severe  forms  of  urethritis  the  principal  change  consists  in  in- 
tense hyperemia,  with  swelling  of  the  mucous  membrane.  This  is  attended 
by  diminution  in  the  caliber  of  the  canal,  which  may  result  in  complete 
retention  of  urine.  AVhen  the  inflammation  is  at  its  height  there  exists 
an  infiltration  of  the  corpus  spongiosum  that  results  in  thickening  and 
inelasticity  of  that  structure.  This  plastic  infiltration  finally  disappears 
entirely  or,  as  is  not  unusual,  localizes  itself  here  and  there.  The  points 
usually  involved  are  the  posterior  boundary  of  the  fossa  navicularis,  the 
lacuna  magna,  and  the  bulbo-membranous  Junction.  Other  points  in  the 
pendulous  urethra  are  frequently  involved.  In  these  situations  we  are  most 
likely  to  find  stricture.  The  urethral  follicles  are  dilated  and  filled  with 
purulent  or  muco-purulent  secretion.  Herpetic  excoriations  are  occasion- 
ally seen.  Considering  the  frequent  great  severity  of  the  inflammation, 
it  is  surprising  that  true  ulceration  does  not  often  occur.  It  is,  however, 
very  rare.  The  urethral  epithelium  is  abraded  here  and  there  in  all  severe 
inflammations.  In  some  instances  it  is  almost  entirely  removed  throughout 
the  canal.  Superficial  erosions  result  from  such  abrasions.  In  chronic 
urethritis  the  pathologic  factors  that  are  most  important  in  explaining 
the  persistency  of  the  disease  are  stricture,  congested  and  granular  patches, 
enlargement  of  the  lacuna  magna,  dilation  and  inflammation  of  the  glands 
of  Littre  and  sinuses  of  Morgagni,  follicular  prostatitis, — i.e.,  so-called 
posterior  urethritis, — and  seminal  vesiculitis. 

The  tendency  to  granulations  in  the  urethra  is  especially  marked  in 
the  bulbous  region.  This  is  worthy  of  note,  as  the  recognition  and  treat- 
ment of  this  condition  by  means  of  the  endoscope  constitute  the  sole  hope 
of  a  cure  in  a  certain  number  of  cases  of  chronic  urethritis. 

The  extent  to  Avhich  the  urethra  is  finally  involved  in  virulent  ure- 
thritis is  a  matter  upon  which  authorities  hold  quite  conflicting  opinions. 
This  would  indicate  a  wide  variation  in  observed  cases.  The  disease  is 
most  severe  in  the  anterior  two  or  three  inches  of  the  canal  in  most  in- 
stances, and  perhaps  may  limit  itself  to  this  region,  but  it  is  probable  that 
the  cases  in  which  it  does  not  extend  so  far  back  as  the  bulb  are  the  ex- 
ception.    The  frequency  with  which  the  posterior  urethra  is  implicated  is 


SYMPTOMS    OF    UEETHEITIS.  127 

still  an  open  question.  It  lias  been  held  in  certain  quarters  that  this 
occurs  sooner  or  later  in  fully  80  per  cent,  of  cases,  as  shown  by  micro- 
scopic examination  of  the  urine.  This  estimate  is  exaggerated;  posterior 
urethritis  has  become  a  fad,  and  no  pains  are  being  spared  to  support  it. 
A  few  lonely  mucous  corpuscles  in  the  last  urine  expelled — using  the  two- 
glass  method — are  all-sufficient  in  certain  quarters  for  the  diagnosis  of 
posterior  urethritis,  despite  the  fact  that  the  patient  has  never  had  a  single 
symptom  of  inflammation  referable  to  the  vesical  neck. 

Period  of  Ixcubation. — The  period  of  incubation  in  urethritis  is 
rather  an  indefinite  quantity.  This,  however,  is  due  to  the  many  sources  of 
confusion.  M.  Leon  le  Fort,  in  a  study  of  over  2000  cases  of  gonorrhea, 
foimd  that  50  developed  within  twenty-four  hours,  778  within  four  days, 
869  between  the  fourth  and  the  eighth  day,  276  from  the  eighth  to  the 
twelfth  day,  112  from  the  twelfth  to  the  sixteenth  day,  and  17  from  the 
sixteenth  to  the  twentieth.  The  author  does  not  accept  these  figures  as 
accurate,  but,  after  making  due  allowance  for  erroneous  observation,  the 
figures  are  still  suggestive  of  the  irregularity  of  incubation.  Le  Fort,  it 
may  be  remembered,  did  not  differentiate  gonococcic  and  simple  urethritis. 

The  incubation  of  true  gonorrhea  can  be  accurately  studied  only  where 
there  has  been  no  ]3revious  disease.  In  cases  due  primarily  to  sexual  ex- 
citement or  irritating  vaginal  discharges,  the  gonococcic  element  may  not 
appear  immediately.  A  discharge  coming  on  within  twenty-four  hours, 
therefore,  may  be  simple  at  first,  and  yet  in  four  or  five  days  become  gono- 
coccic. Simple  urethritis  may  develop  at  any  time  after  exposure  to  its  ex- 
citing causes,  the  length  of  time  varying  with  the  strength  of  the  irritant 
and  the  susceptibility  of  the  urethra,  every  urethra  being  a  law  unto  itself. 
The  gonococcic  type  supervenes  upon  the  simple  variety  or  occurs  primaril}^, 
on  the  average,  about  the  fourth  or  fifth  day  after  exposure.  The  author 
was  at  one  time  inclined  to  repudiate  the  incubation  period  altogether,  but 
has  lately  come  to  believe  in  its  existence  in  typic  gonococcic  urethritis,  due 
consideration  being  given  to  such  sources  of  confusion  as  previous  urethral 
disease  and  varied  exposures  to  possible  infection. 

Symptoms. — The  symptomatology  of  urethritis  requires  little  attention. 
Eicord  was  not  far  from  right  when  he  said:  "Anybody  can  tell  when  a 
gonorrhea  begins,  but  God  alone  knows  when  it  will  end."  Modern  methods 
have  modified  this  dictum  of  one  of  the  masters  somewhat,  but  not  to  a 
degree  that  would  warrant  us  in  exulting  over  the  progress  made. 

The  symptoms  of  simple  urethritis  consist  of  a  slight  or  moderate 
urethral  discharge  of  a  muco-purulent  character,  with  perhaps  more  or  less 
smarting  on  urination.  The  discharge  develops,  as  a  rule,  shortly  after 
venereal  excesses  or  intemperance  in  gouty  or  rheumatic  patients  with 
damaged  urethras,  or  in  those  suffering  from  stricture  with  granular  con- 
gested patches  in  the  canal  independently  of  any  special  diathesis.  It  may 
occur  in  individuals  with  healthy,  but  sensitive,  urethras,  as  a  result  of 


128  rKETHEITIS    AXD    GOXOEEHEA. 

contact  witli  morbid,  irritating  vaginal  secretions.  It  is  to  be  remembered 
that  the  simple  type  of  inflammation  may  at  any  time  become  very  severe 
and  Tirnlent  from:  (a)  coincident  gonococcic  infection,  and  (h)  yarious 
sources  of  superadded  irritation. 

The  symptoms  of  typic  gonococcic  urethritis  are  quite  characteristic. 
At  the  end  of  the  period  of  incubation  there  is  more  or  less  itching  at 
'  the  meatus,  with  smarting  on  urination.  The  meatus  is  glued  together 
with  a  clear,  sticky  deposit  of  mucus.  During  the  second  day  an  increase 
of  discharge  is  observed,  accompanied  b}^  considerable  heat  and  painful 
micturition.  These  symptoms  gradually  increase  until  about  the  fifth  to 
the  seventh  da}",  at  which  time  the  disease  reaches  its  maximum  degree  of 
severity.  The  inflammation  now  becomes  stationary,  the  discharge  being 
thick,  creamy,  and  of  a  greenish  color,  due  to  degenerated  blood-corpus- 
cles. In  some  instances  distinct  hemorrhage  occurs;  slight  hemorrhages 
from  capillary  rupture  are  by  no  means  infrequent.  The  more  virulent  the 
case,  the  more  greenish  and  profuse  the  pus,  as  a  rule,  and  the  greater  the 
liability  to  hemorrhage.  In  some  cases,  however,  there  is  such  severe  in- 
flammation that  the  discharge  is  merely  a  thin,  greasy,  muco-sanious  fluid. 
So  soon  as  the  inflammation  begins  to  subside,  the  discharge  becomes  thick, 
creamy,  and  purulent,  but  is  still  of  a  greenish  hue.  During  the  stationary 
period  the  patient  is  most  apt  to  have  chordee;  this  consists  of  a  painful 
bending  of  the  penis  during  erection,  and  is  due  to  interstitial  inflamma- 
tion of,  and  plastic  exudate  into,  the  corpus  spongiosum  and  the  submucous 
connective  tissue  surrounding  the  urethra.  "When  the  organ  is  erect  the 
inflamed,  infiltrated,  and  inelastic  corpus  spongiosum  acts  upon  the  body 
of  the  penis  (the  corpora  cavernosa)  like  the  string  of  a  bow  and  causes  it 
to  bend.  The  corpus  spongiosum  being  highly  sensitive,  severe  pain  re- 
sults from  its  own  resistance  to  erection. 

There  is  a  popular  notion  that  breaking  a  chordee  will  cure  urethritis. 
This  was  probably  because  more  or  less  benefit  has  been  noticed  from  the 
depletion  due  to  the  resulting  hemorrhage,  and-  also  probably  because  the 
rupture  has  often  occurred  at  a  time  when  the  inflammation  naturally 
begins  to  subside.  The  patient  should  be  enlightened  upon  this  point,  and 
informed  that  such  a  course  will  result,  in  all  probability,  in  severe  hemor- 
rhage, and  inevitably  in  organic  stricture.  Even  when  the  mucous  mem- 
brane alone  is  infiltrated,  it  becomes  less  elastic;  consequently,  when  erec- 
tion occurs,  even  without  chordee,  considerable  pain  may  result.  During 
erection  slight  traumatisms  of  the  mucous  membrane  may  occur:  these 
are  a  foundation  for  organic  stricture.  This  is  a  very  important  point.  It 
is  unfortunate  that  disease  or  injury  of  the  penis  or  urethra  irritates  and 
increases  the  heat  of  the  parts,  and  reflexly  produces  frequent  and  vigorous 
erections. 

"When  the  disease  is  at  its  height  there  may  be  general  constitutional 
disturbance,  severe  urethritis  often  causing'  considerable  fever.     Pain  and 


COMPLICATIONS    OF    UEETHEITIS.  129 

heat  about  the  parts,  a  sense  of  dragging  along  the  spermatic  cord,  neu- 
ralgic pain  in  the  testicles,  and  severe  backache  resembling  lumbago  are 
often  observed. 

After  remaining  stationary  for  perhaps  a  week  or  more,  the  inflam- 
mation begins  to  decline,  all  of  the  symptoms  decreasing  in  intensity.  In 
a  majority  of  carefully-treated  cases  the  discharge  ceases  in  from  three  to 
six  weeks,  with  apparently  complete  recovery.  Unfortunately,  however, 
there  is  often  a  tendency  to  chronicity  in  spite  of  judicious  treatment,  the 
discharge  becoming  thinner  and  more  watery  and  persisting  for  an  in- 
definite period.  This  condition — or  rather  symptom — is  what  is  popularly 
termed  gleet. 

ComplicatiojSTS. — In  considering  the  complications  of  urethral  inflam- 
mation the  author  will  endeavor  to  give  only  the  main  practical  points.  An 
■exhaustive  discussion  of  the  subject  would  require  more  space  than  it  is 
practicable  to  devote  to  them  in  a  single  treatise. 

Most  complications  are  due,  not  to  the  intrinsic  pathologic  tendencies 
of  the  disease  per  se,  but  to  irrational  general  management  or  overenthu- 
siastic  attempts  at  a  cure.  The  frequency  of  complications  is  proportionate 
to  the  energy  expended  in  treatment.  Under  rational  management,  with 
treatment  largely  expectant  in  cases  that  are  fully  developed,  urethritis  is 
not  usually  attended  by  many  or  severe  complications.  The  danger  of  com- 
plications is  dependent  upon  the  severity  of  the  inflammation  and  the  de- 
gree and  frequency  with  which  the  canal  is  mechanically  disturbed  in  severe 
cases.  The  amount  of  exercise  indulged  in  is  an  important  factor.  As  for 
the  etiology  of  complications,  the  gonococcus  is  by  no  means  the  principal 
factor.  Gonorrhea  is  a  typically-mixed  infection;  many  of  its  complications 
are  not  immediately  dependent  upon  the  gonococcus. 

The  principal  complications  of  urethritis  are:  (1)  severe  chordee;  (2) 
hemorrhage;  (3)  folliculitis;  (4)  periurethral  phlegmon;  (5)  retention  of 
urine  from  inflammatory  or  spasmodic  stricture;  (6)  prostatitis;  (7)  Cow- 
peritis;  (8)  cystitis;  (9)  epididymitis  and  orchitis;  (10)  gonorrheal  rheu- 
matism; (11)  gonorrheal  ophthalmia;  (12)  gonorrheal  conjunctivitis;  (13) 
bubo;  (14)  balanitis  and  balanoposthitis;  (15)  papillomata;  (16)  lymphan- 
gitis. 

Chordee. — Severe  chordee  and  hemorrhage  are  naturally  associated. 
Chordee  develops  when  the  inflammation  is  at  its  maximum  intensity,  at 
which  time  the  plastic  exudate  is  most  marked.  It  gives  rise  to  no  incon- 
venience excepting  during  erection.  Pain  is  therefore  usually  experienced 
only  at  night.  The  penis  during  erection  may  be  bent  to  one  or  the  other 
side  or  twisted.  The  principal  dangers  are  rupture  and  hemorrhage,  with 
:subsequent  stricture  or  perhaps  abscess. 

Folliculitis. — Localized  inflammation  of  mucous  follicles  may  occur 
at  any  time  during  acute  urethritis,  and  sometimes  in  the  subacute  and 
-chronic  types.     Small,  tender,  spheric,  or  oval  swellings  from  the  size  of 


130 


UEETHEITIS    AXD    GOXOEKHEA. 


a  small  shot  to  that  of  a  pea  appear  along  the  floor  of  the  canal,  especially 
anteriorly.  The  condition  is  due  to  infection  of  the  urethral  follicles  and 
sinuses  of  Morgagni,  with  resultant  small  retention-cysts  containing  pus 
and  mucus.  They  rarely  lead  to  serious  trouhle,  usually  discharging  into 
the  urethra.    They  may  be  the  source  of  recurrent  urethral  infection. 

PeriiiretliraJ  Phlegmon. — This  is  a  frequent  complication  of  urethritis. 
It  is  an  inflammation  of  the  periurethral  cellular  tissue  due  to:  (1)  minute 
rupture  of  the  mucous  membrane,  with  resulting  periurethral  infection; 
CZ)  rupture  of  inflamed  and  infected  follicles;  (3)  infection  of  the  cellular 
tissue  via  the  lymjDhatics  or  by  migration  of  pus-microbes;   (4)  rupture  and 


Fig.  37. — Periurethral  phlegmon.     (After  Hardy.) 

extravasation  of  the  urethra  behind  a  stricture.  All  these  complications 
imply  either  extension  by  contiguity  via  the  mucous  ducts  or  an  abrasion 
of  epithelium  with  resultant  absorption  of  germ-products.  Phlegmonous 
inflammation  usually  ends  in  suppuration,  but  resolution  may  occur  with- 
out it.     The  favorite  seat  of  phlegmon  is  the  floor  of  the  fossa  navicularis. 

Eetention  of  Urine. — Eetention  of  urine  is  essentially  the  same  as  when 
due  to  other  causes.  It  depends  on  inflammatory  swelling  of  the  mucous 
and  submucous  tissues  in  conjunction  with  deep  muscular  spasm.  This  is 
the  so-called  congestiye  or  inflammatory  stricture,  and  may  be  precipitated 
by  sexual  or  dietetic-  excesses  or  indiscretions. 

Acute  Prostatitis. — Prostatic  inflammation  is  a  frequent  complication 


COMPLICATIOXS    OF    URETHEITIS.  131 

of  urethritis.  It  will  be  discussed  in  connection  with  diseases  of  the  pros- 
tate. 

Cou-peritis. — Inflammation  of  Cowper's  glands  occasionally  occurs.  It 
is  due  to  simple  extension  of  the  infectious  inflammation  to  these  glands, 
which  lie  upon  either  side  of  the  urethra  behind  the  bidb  and  between  the 
layers  of  the  triangular  ligament.  It  is  usually  unilateral,  but  may  involve 
both  sides. 

Symptoms. — The  symptoms  are  pain,  swelling,  throbbing,  and  a  feel- 
ing of  tension  in  the  perineum.  Early  examination  detects  a  small  sensi- 
tive tumor  the  size  of  a  pea;  later  on  the  perineum  becomes  swollen,  hard, 
and  brawny,  and  it  is  impossible  to  outline  the  inflamed  gland.  Swelling, 
reddening,  and  edema  of  the  scrotum  may  occur.  There  is  likely  to  be  con- 
siderable constitutional  disturbance  incidental  to  the  close  confinement  of 
the  inflammatory  exudate  within  the  triangular  ligament.  Suppuration 
usually  occurs,  but  resolution  occasionally  takes  place  without  it. 

Gonorrheal  cystitis,  orchitis,  epididymitis,  and  seminal  vesiculitis  will 
receive  consideration  in  connection  with  the  diseases  of  the  bladder,  testes, 
and  seminal  vesicles,  respectively. 

Gonorrheal  Rheumatism. — Gonorrheal  rheumatism  is  a  relatively-infre- 
quent complication  or  sequel  of"  gonorrhea.  Its  existence  is  disputed  by 
some  surgeons,  but  the  majority  of  authorities  admit  that  certain  indi- 
viduals, who  are  oftentimes  apparently  free  from  predisposition  to  ordinary 
rheumatism,  experience  pain  and  tenderness  of  the  joints,  attended  with 
more  or  less  constitutional  disturbance  and  synovial  effusion,  in  the  course 
of  gonorrhea,  while  in  others  the  process  attacks  various  tendinous  and 
ligamentous  structures.  Some  patients  are  affected  with  this  complication 
with  every  attack  of  specific  urethritis.  It  rarely  begins  during  the  acute 
stage,  being  most  likely  to  occur  after  the  disease  has  become  chronic. 
The  writer  has  known  it  to  occur,  however,  within  three  days  after  the 
onset  of  the  disease. 

Few  diseases  have  been  the  source  of  more  controversy  regarding  their 
origin  than  has  gonorrheal  rheumatism,  but  as  yet  its  pathology  must  be 
regarded  as  unsettled.  It  does  not  seem  to  depend  upon  atmospheric  con- 
ditions, overexertion,  nor,  it  is  claimed,  the  method  of  treatment  of  gonor- 
rhea, the  latter  proposition,  however,  being  open  to  doubt.  The  affection 
sometimes  follows  abortive  treatment  by  silver  solutions  with  suspicious 
rapidity.  The  relation  of  the  disease  to  inflammation  of  the  urethra  is  all 
that  has  so  far  been  proved.  Actual  suppuration  of  the  mucous  membrane 
is  by  no  means  necessary  in  its  causation.  It  has  been  claimed  that,  inas- 
much as  it  occurs  independently  of  the  ordinary  causes  of  rheumatism  and 
occurs  in  such  a  small  proportion  of  cases  of  urethritis,  it  is  due  to  idiosyn- 
crasy.    There  may  be  some  truth  in  this  view. 

The  most  universal  opinion  is  that  gonorrheal  rheumatism  is  a  mild 
sort  of  systemic  infection  by  the  products  of  urethral  inflammation.     Ac- 


132  UEETHEITIS    AXD    GOXOEKHEA. 

cording  to  some,  the  disease  is  due  to  secondary  infection,  the  gonococcus 
having  been  found  in  arthritic  and  tendinous  effusions.  It  is  probable  that 
toxins  elaborated  by  the  virulent  germ-infection  enter  the  circulation  and 
finally  reach  the  affected  parts.  The  joint-tissues  are  sometimes  extraordi- 
narily sensitive,  and  arthritic  effusion  occurs.  Whether  gonococci  or  the 
toxins  of  mixed  infection  are  the  exciting  cause  of  the  affection  is  unset- 
tled. Pus-microbes  probably  cause  the  exceptional  cases  characterized  by 
suppuration.  General  pus-infection  has  resulted  from  gonorrhea,  thus 
Chart eris,  in  1ST 6,  reported  the  case  of  a  youth  who  died  of  pyemia  on  the 
sixth  day  after  developing  virulent  urethritis.^  General  gonococcic  infec- 
tion with  endocardial  involvement  has  been  observed,  and  verified  post- 
mortem. Certain  elements  in  the  treatment  of  gonorrhea  may  be  the 
primary  cause.  The  destructive  effect  exerted  by  strong  injections  and  the 
rude  introduction  of  instruments  upon  the  epithelium  of  the  urethra  has 
already  been  noted.  If  the  mucous  membrane  be  abraded  absorption  of 
organic  poisons  is  facilitated.  Absorption  does  not  readily  occur  through 
the  intact  mucous  membrane,  when  inflamed.  The  facility  of  absorption 
in  certain  individuals  may  explain  their  special  susceptibility.  The  im- 
munity of  women  is  suggestive.  The  only  explanation  of  this  immunity 
is  the  relative  toughness  of  the  vagina  and  endometrium.  When  the  dis- 
ease does  occur  in  the  female  the  urethra  and  bladder  will  be  found  to  be 
involved.  Eheumatism  does  not  usually  follow  primarily  simple  urethritis, 
showing  that  the  degree  of  virulence  is  an  etiologic  factor.  Whether 
gonorrheal  rheumatism  is  always  due  to  gonococcic  urethritis  is  open  to 
question.  The  disease  arises  in  cases  where  there  is  no  evidence  of  speci- 
ficity in  spite  of  the  severity  of  the  urethral  disease. 

The  author  believes  that  cachectic,  strumous,  gouty,  and  rheumatic 
patients  are  more  predisposed  to  the  disease  than  healthy  persons. 

Symptoms. — The  disease  resembles  rheumatic  gout  rather  than  ordi- 
nary rheumatism.  The  local  evidences  of  the  disease  are  not  usually  severe, 
nor  the  constitutional  symptoms  marked;  but  this  is  not  always  true.  The 
disease  comes  on,  as  a  rule,  during  the  decreasing  stage:  sometimes  during 
the  second  or  third  month.  Some  authorities  claim  that  it  usually  de- 
velops in  from  five  to  sixteen  days.  Most  cases  observed  by  the  author  have 
occurred  later,  although,  as  above  stated,  one  case  developed  within  three 
days  after  the  onset  of  urethritis.  In  another  case  only  a  week  had  elapsed. 
The  explanation  that  suggests  itself  is  that  inflammatory  thickening  inhibits 
absorption  to  a  certain  extent.  Then,  too,  epithelial  abrasion  is  not  so  apt 
to  occur  within  the  first  few  days  as  later  on.  when  the  infectious  material 
has  been  in  contact  with  it  for  some  time.  The  products  of  the  purulent 
process  are  not  so  virulent  in  the  first  few  days  as  afterward. 

There   is  usuallv  no   chanoe   in  the   urethral   discharge   coincidentlv 


^  British  INIedical  Journal. 


COMPLICATIONS    OF   UEETHRITIS.  133 

with  the  development  of  the  rheumatism;  it  may  be  lessened,  probably 
because  the  arthritis  compels  the  patient  to  keep  quiet.  In  some  cases  cessa- 
tion or  marked  diminution  of  discharge  occurs  and  cannot  be  explained. 
This  is  not  likely  to  benefit  the  urethritis.  It  is  doubtful  whether  gonor- 
rheal rheumatism  ever  acts  as  a  revulsive  or  derivative  upon  the  urethral 
inflammation.  It  is  said  that  when  the  rheumatism  comes  on  late  there  is 
liable  to  be  an  increased  discharge  for  a  few  days.  The  propter  and-/JOS^  are 
probably  confounded.  It  is  more  probable  that  from  some  particular  cause 
exacerbation  of  the  urethritis  occurs,  with  a  coincident  rapid  formation  of 
its  characteristic  toxic  products;  the  mucous  membrane  of  the  urethra  being 
extensively  abraded  at  this  time,  absorption  readily  occurs. 

The  seat  of  gonorrheal  rheumatism  varies  in  different  individuals; 
sometimes  in  the  same  patient  in  different  attacks. 

The  structures  involved,  in  the  order  of  frequency,  are:  (1)  the  articula- 
tions; (2)  the  synovial  sheaths  of  tendons  and  muscles;  (3)  synovial  bursas 
and  the  sheaths  of  nerves.  Associated  with  the  latter  form  inflammation 
of  the  pericardium,  endocardium,  the  cerebral  meninges,  and  the  deeper 
structures  of  the  eye  may  occiir.  The  author  has  seen  a  number  of  cases  in 
which  the  eye  alone  was  involved.  There  is  a  marked  predilection  for  the 
more  important  joints,  the  knee  being  most  often  affected.  As  a  rule,  the 
inflammation  is  most  severe  in  one  joint,  although,  in  most  instances,  sev- 
eral joints  are  eventually  involved. 

Vaeieties. — Fournier's  classification  embraces  three  forms: — 

1.  Generally  monoarticular  inflammation,  most  often  of  the  knee, 
sometimes  the  ankle  or  elbow.  This  is  a  passive,  insidious  hydrarthrosis 
with  much  effusion.  Pain,  tenderness,  redness,  heat,  and  constitutional 
disturbance  are  absent  or  moderate.  Eesolution  is  very  gradual,  and  usu- 
ally takes  some  months.  Ankylosis  may  occur.  The  monoarticular  form 
is  sometimes  excessively  painful  and  attended  by  marked  constitutional 
disturbance.  It  tends  to  affect  the  bones  of  the  articulation  ^secondarily. 
The  fluid  in  such  cases  is  likely  to  contain  more  or  less  purulent  material. 

2.  A  variety  resembling  articular  rheumatism.  This  is  accompanied 
by  moderate  local  and  constitutional  symptoms.  Several  points  are  usu- 
ally involved:  the  tendons,  various  other  fibrous  structures,  and  the  eye 
are  often  implicated.  The  symptoms  are  milder  than  those  of  acute  rheu- 
matism, very  mild  considering  the  apparent  magnitude  of  the  processes. 

The  disproportion  between  the  general  and  local  symptoms  is  impor- 
tant in  differential  diagnosis.  The  involvement  of  the  joints  is  usually 
consecutive,  but  there  is  no  articular  delitescence  as  in  acute  rheumatism. 
The  profuse  sweating,  acid  urine,  and  excessive  plasticity  of  the  blood, 
characteristic  of  inflammatory  rheumatism,  are  usually  absent  in  the  gonor- 
rheal variety.  The  serous  membranes,  the  pleura,  endocardium,  and  peri- 
cardium are  not  often  attacked.  A  favorable  result  is  usual,  but  chronic 
synovitis,  tubercular  arthritis  in  certain  subjects,  joint-stiffness,  and  com- 


134  UEETHEITIS    AXD    GOXOEEHEA. 

plete  ankylosis  are  possible  sequels.  Foiirnier  claims  that  acute  suppura- 
tion does  not  occur;  it  is,  however,  occasionally  seen.  A  Joint  may  con- 
tain considerable  purulent  fluid  and  still  recover  without  radical  surgical 
interference.     This  is  not  likely  in  ordinary  suppurative  arthritis. 

3.  (a)  Indeterminate  transitory  pains  in  various  joints  without  either 
local  or  general  evidences  of  disease.  There  is  apt  to  be  exacerbation  of 
pain  and  perhaps  distinct  involvement  of  joints  coincidently  with  in- 
crease in  the  urethral  inflammation.  (&)  Thecitis,  the  synovial  sheaths 
becoming  swollen  and  tender,  jserhaps  with  moderate  redness  along  the 
afl'ected  tendon.  Movement  of  the  corresponding  muscle  is  very  painful. 
Synovial  bursa?  may  become  involved;  those  under  the  tendo  Achillis  and 
the  inferior  tuberosity  of  the  os  calcis  are  most  susceptible.  Patients  thus 
affected  complain  of  pain  and  tenderness  in  the  heel.  This  s3-mptom  is 
not  rare  in  gonorrhea. 

Gonococci  have  been  found  in  numerous  forms  of  gonorrheal  rheuma- 
tism. Myalgia  and  perineuritis  sometimes  occur  in  gonorrhea.  Pain  in  the 
back  of  a  severe  character,  simulating  acute  lumbago,  is  very  frequently 
seen.  This  is  usually  due  to  overstimulation  of  the  kidneys  by  various 
balsamic  preparations,  especially  sandal-wood.  It  occurs,  however,  where 
such  drugs  have  not  been  taken.  AVhether  reflex  nephralgia  explains  these 
latter  cases  is  an  open  question. 

Cases  are  met  with  where  gonorrheal  rheumatism  limits  itself  to  a 
single  nerve.  One  of  the  author's  patients  has  sciatica  with  every  attack 
of  gonorrhea.  Even  simple  urethritis  brings  it  on  in  this  patient.  The  first 
attack  of  gonorrhea  that  he  ever  experienced  was  attended  b}^  severe 
sciatica,  involving  both  nerves. 

It  is  remarkable  that  authorities  so  universally  concede  the  compara- 
tive painlessness  of  gonorrheal  rheumatism  when  many  cases  are  attended 
by  severe  pain  and  not  infrequently  by  sweats  quite  as  profuse  as  those  of 
ordinary  acute  rheumatism.  The  tendency  to  sweating  seems  to  be  most 
marked  at  night,  being  characterized  b}'  absence  of  acidity,  its  prostrating 
character,  and  great  profuseness. 

Bubo. — The  adenopathic  complications  of  urethritis  have  received  at- 
tention under  the  general  head  of  bubo. 

Balanitis,  halanoposthitis,  and  lijmphangitis  complicating  gonorrhea 
are  the  same  as  when  occurring  under  other  conditions.  The}^  have  already 
been  discussed. 

Teeatmext  of  Ubetheitis. — Urethritis  has  been  treated  by  a  great 
variety  of  remedies.  This  is  strong  circumstantial  evidence  of  its  self- 
limited  and  often  intractable  character.  Manifold  as  are  the  "specifics" 
for  urethritis,  no  system  of  treatment  has  materially  diminished  its  average 
duration  and  severity,  save  those  measures  based  upon  its  self-limitation 
with  due  appreciation  of  the  inadvisability  and  impracticability  of  attempts 
to  jugulate  it,  after  it  has  fairly  developed.     Such  measures  of  treatment 


TEEATMENT  OF  UEETHEITIS.  135 

have  aceomplisliecl  much;  specifics,  notliing  hut  injury,  on  tlie  average. 
There  is  scarcely  a  physician,  and  probably  not  a  man  about'  town,  but 
claims  to  have  a  sure  cure  for  the  "clap,"  the  different,  remedies  varying  in 
position  and  legitimacy  from  the  fallacious  and  dangerous  patent  injections 
to  the  more  modern  application  of  the  bichlorid  of  mercury  by  the  retro jec- 
tion  method.  The  statements  of  surgeons  who  claim  to  cure  cases  of  yirulent 
urethritis  in  a  week  or  ten  days  or  perhaps  less,  are  to  be  discredited  quite 
as  much  as  the  claims  of  the  lay  veteran  who  has  a  wonderful  three-day 
cure.  The  author  has  hunted  down  all  the  wonderful  specifics  that  have 
ever  been  called  to  his  attention,  and  has  tried  them  all  faithfully,  but  has 
not  yet  succeeded  in  obtaining  the  wonderful  results  claimed  by  some  sur- 
geons and  self -deluded  laymen.  Mr.  Milton  has  well  illustrated  the  fal- 
laciousness of  gonorrheal  specifics  in  a  list,  taken  from  various  sources, 
comprising  several  hundred  infallible  remedies,  all  of  which  have  been  tried 
and  found  wanting.  A  remedy  for  self-administration  that  will  cure  the 
majority  of  cases,  even  in  from  three  to  six  weeks,  will  be  hailed  as  one  of 
the  greatest  discoveries  of  the  age.  What  has  been  said  of  the  fallacy  of 
most  forms  of  specific  treatment  does  not  arbitrarily  apply  to  the  method 
of  Janet — so  called — by  permanganate  irrigations,  providing  treatment  is 
legun  during  the  incipiency  of  the  disease  and  carried  out  for  from  three  to 
six  iveelis  or  more. 

The  surgeon  who  includes  cases  of  simple  urethritis  in  his  statistics 
may  achieve  a  certain  proportion  of  speedy  cures.  This  remark  is  particu- 
larly pertinent  when  M^e  consider  the  fact  that  the  average  surgeon  treats 
many  more  simple  than  virulent  cases.  AVith  due  regard  to  the  self-limita- 
tion of  the  disease  and  the  intolerance  of  the  urethra  for  harsh  treatment, 
fewer  cases  of  urethritis  will  become  chronic  and  fewer  strictures  and  other 
sequels  will  result  than  with  systems  of  treatment  that  aim  to  cure  within  a 
few  days.  There  are,  to  be  sure,  cases  that  are  likely  to  shake  our  faith  in 
this  rational  method  of  management.  How  often  we  meet  with  the  self- 
satisfied  voluptuary  who  years  ago  had  a  gonorrhea  that  proved  obstinate  to 
the  best  professional  skill  for  months  and  months,  but  who  now  has  a  pre- 
scription that  has  speedily  cured  him  of  numerous  attacks.  Such  cases 
should  not  shake  the  surgeon's  faith  in  rational  methods.  The  only  virulent 
urethritis  such  patients  ever  had  Avas  the  first  attack,  from  contagion,  subse- 
quent attacks  having  been  simple  inflammation  founded  upon  chronic  con- 
ditions left  by  the  old-time  gonorrhea.  Sooner  or  later  a  second  attack 
of  virulent  urethritis,  or  perhaps  a  mild  case  with  a  tendency  to  chronicity, 
is  experienced,  and  necessitates  surgical  measures  for  the  removal  of  the 
cause  of  those  frequent  "attacks"  that  the  alleged  specific  so  readily  subdued. 

As  illustrative  of  the  fallacy  of  some  published  reports  of  the  efficacy 
of  specific  drugs  in  the  cure  of  gonorrhea  may  be  mentioned  a  clinical  "essay" 
on  a  new  urethral  antiseptic  published  soon  after  its  introduction.  A  prac- 
titioner Avho  had  entered  metropolitan  practice  only  a  short  time  previously 


136  URETHRITIS    AND    GONORRHEA. 

reported  something  like  one  linndred  cases  of  acute  gonorrhea  that  he  had 
cured  with  the  new  drag  in  from  three  or  four  daj^s  to  two  or  three  weeks. 
In  a  recent  conversation  with  the  representative  of  the  house  for  whom 
the  article  Avas  written^  the  author  was  informed  that  the  "essayist"  has 
practically  abandoned  the  wonderful  specific.  Has  he  found  a  more  speedy 
cure  or  a  more  liberal  manufacturer?  Such  contributions  are  only  too 
numerous,  and  hold  their  authors  up  to  suspicion,  of  their  accuracy  at  least, 
if  not  to  ridicule. 

jSTotwithstanding  the  establishment  of  the  microbe  of  virulent  ure- 
thritis, there  has  been  no  remarkable  improvement  in  methods  of  treat- 
ment. This  certainly  signiiies  the  self-limitation  of  the  disease.  Bac- 
teriologists who  have  implicit  faith  in  the  gonococcus  have  shown  that  the 
disease  infects  the  mucous  membrane  and  submucous  cellular  tissue  so  thor- 
oughly that  repair  cannot  take  place  in  marked  cases  until  the  la3^ers  of 
affected  cells  have  been  replaced  by  new  and  insusceptible  connective-tissue 
and  epithelial  cells.  This  proves  that  nothing  short  of  complete  destruc- 
tion of  the  affected  tissues  can  possibly  abort  virulent  urethritis  when  once 
thoroughly  established.  Attempts  to  abort  the  disease  should  therefore  be 
made  only  in  its  incipieney.  To  be  effectual  any  form  of  germicide  treat- 
ment must  be  applied  within  a  few  hours  after  the  inception  of  the  disease. 
The  gonococcus  causes  irritation  of  the  urethral  mucous  membrane  very 
soon  after  its  introduction  into  the  canal,  and  if  the  germs  be  destroyed 
in  loco,  the  disease  not  having  yet  fairly  begun  may  be  said  to  have  been 
aborted — or,  perhaps  more  properly  speaking,  prevented. 

In  concluding  the  general  consideration  of  the  treatment  of  urethritis 
the  author  takes  occasion  to  reiterate  the  fact  that  the  disease  is  rarely 
treated  upon  rational  principles.  The  patient  expects  more  from  the  sur- 
geon, and  the  latter  expects  more  from  remedies,  than  in  almost  any  other 
disease.  The  fallacious  notion  of  the  simplicity  of  gonorrhea  and  its  con- 
geners has  proved  disastrous.  Physicians  should  embrace  every  opportu- 
nity to  impress  the  patient  with  the  fact  that  gonorrhea  is  one  of  the  most 
severe  and  perhaps  the  most  far-reaching  in  its  results  of  all  the  infectious 
diseases.  It  is  not  only  worse  than  a  bad  cold,  contrary  to  the  lay  opinions 
upon  the  subject,  but  it  is  far  worse  than  its  much-dreaded  rival  for  venereal 
popularity — syphilis. 

Abortive  Treatment.- — The  abortive  method  of  treatment  has  generally 
implied  the  substitution  of  simple  for  specific  inflammation.  This  practice 
is  a  relic  of  by-gone  days  that  has  impelled  surgeons  of  undoubted  wisdom 
in  other  directions  to  apply  pure  nitrate  of  silver  in  virulent  conjunctivitis. 
Possibly  there  are  surgeons  even  now  who  advocate  this.  During  the  au- 
thor's term  of  service  as  a  hospital-interne  less  than  twenty  years  ago  he  saw 
pure  nitrate  of  silver  applied  on  several  occasions,  and  in  every  instance  it 
was  followed,  not  by  "the  substitution  of  a  simple  for  a  specific  inflamma- 
tion," but  by  complete  destruction  of  vision. 


ABORTIVE    TREATMENT    OF    URETHEITIS.  137 

The  abortive  method  of  treatment  of  urethritis  should  not  be  directed 
to  the  substitution  of  one  type  of  inflammation  for  another,  but  (1)  to  the 
removal  of  the  virulent  germs  from  the  surface  of  the  mucous  membrane, 
which  germs,  although  already  causing  slight  irritation  at  or  near  the 
meatus,  have  not  yet  deeply  penetrated  the  mucous  membrane  and  infected 
the  subjacent  cells;  and  (2)  neutralization  of  the  germs  and  their  products 
by  antiseptics  or  germicides,  in  strength  capable  of  destroying  or  inhibiting 
the  activity  of  the  germs  without  injuring  the  mucous  membrane.  These 
requirements  are  the  more  readily  fulfilled  because  the  disease  begins  ante- 
riorly, and  gradually  affects  contiguous  areas  of  mucous  membrane. 

The  substance  most  generally  used  in  the  abortive  method  is  silver 
nitrate.  This  may  be  used  in  two  ways:  (1)  by  repeated  injections  of  a 
mild  solution;  (2)  by  a  single  injection  of  a  comparatively-strong  solution. 
If  properly  employed  in  the  very  incipiency  of  the  disease,  either  of  these 
methods  is  usually  safe  and  effective.    A  solution  of  silver  nitrate,  15  grains 


Fig.  38. — Lydston's  urethral  irrigator. 

to  the  ounce,  may  be  injected  with  a  small  medicine-dropper;  this  is  passed 
into  the  urethra  for  about  two  inches,  the  fluid  being  ejected  as  the  syringe 
is  slowly  withdrawn.  The  solution  should  be  held  in  the  urethra  for  a  few 
seconds,  a  weak  solution  of  sodium  chlorid  or  bicarbonate  then  injected, 
and  the  patient  instructed  to  urinate.  If  carefully  done  when  slight  dis- 
charge and  itching  at  the  meatus  are  first  observed,  the  method  is  apt  to 
prove  successful  and  is  devoid  of  danger.  In  lieu  of  the  strong  preparation 
a  solution  of  ^/^  grain  to  the  ounce  may  be  used  every  two  hours  for  twenty- 
four  hours  or  less,  the  treatment  being  stopped  so  soon  as  severe  smarting 
during  micturition  develops.  That  silver  nitrate  destroys  the  germs  of 
gonorrhea  has  been  well  shown  by  the  Crede  method  of  prophylaxis  of 
ophthalmia  neonatorum.  A  solution  of  silver  may  be  used  by  anterior  irri- 
gation with  a  view  to  aborting  the  infection. 

The  best  method  for  the  abortion  of  urethritis  is  prolonged  and  sys- 
tematic irrigation  of  the  anterior  urethra  with  solution  of  potassium  per- 
manganate 1  in  5000  to  1  in  3000.     This  should  be  used  as  warm  as  can 


138  UEETHEITIS    AKD    GOXOEEHEA. 

be  comfortably  borne,  and  used  in  large  quantity — half  a  gallon  at  least. 
This  should  be  repeated  twice  daily  for  three  or  four  days,  after  which  time 
one  daily  irrigation  for  two  or  three  weeks  should  be  given.  Care  should 
be  taken  not  to  use  the  water  too  hot,  as  the  urethral  epithelium  is  easily 
destroyed;    this  is  too  often  forgotten. 

Long  nozzles  for  irrigation  are  bad.  The  author  has  found  a  short  and 
inexpensive  nozzle  of  his  own  device  (Fig.  38)  to  be  quite  satisfactory.  The 
irrigations  should  be  given  either  with  a  glass  percolator  or  a  fountain- 
syringe.  Care  should  be  taken  not  to  elevate  the  douche-bag  too  much,  else 
injurious  pressure  upon  the  urethral  walls  may  result.  During  the  course 
of  irrigations  the  usual  hygienic  and  internal  treatment  should  be  employed. 
It  is  sometimes  well  to  combine  the  administration  of  oil  of  sandal-wood 
with  the  irrigation  method.  Valentine's  irrigator  is  an  excellent  appliance 
for  urethral  irrigation. 

Caution  is  necessary  in  the  matter  of  too  speedy  cessation  of  treatment. 
As  a  rule,  the  discharge  ceases  within  twenty-four  hours;  hence  it  is  dif- 
ficult to  convince  patients  of  the  necessity  of  continuing  treatment.  Ex- 
perience shows  prolonged  treatment  to  be  necessary,  else  the  disease  will 
simply  be  retarded,  not  jugulated. 

Where  frequent  irrigations  are  impracticable  permanganate  solutions 
may  be  employed  by  ordinary  injections.  Much  stronger  solutions  are 
tolerated  than  in  irrigations.  A  solution  of  1  in  5000  may  at  first  be  used 
every  two  hours,  the  treatment  being  concluded  by  filling  the  urethra  full 
of  the  solution  and  retaining  it  for  ten  or  fifteen  minutes.  The  strength  of 
the  solution  may  be  gradually  increased  up  to  1  in  1500. 

Systematic  Treatment. — It  is  obvious  that  the  field  for  abortive  treat- 
ment of  urethritis  is  limited.  Comparatively  few  cases  come  under  oId- 
servation  before  the  disease  has  so  far  advanced  that  abortive  treatment 
not  only  promises  nothing,  but  is  likely  to  be  positively  harmful.  In  most 
instances,  therefore,  we  are  compelled  to  rely  upon  rational,  systematic 
treatment  adapted  to  the  various  phases  of  the  disease  and  founded  upon 
a  knowledge  of  its  normal  evolution. 

In  simple  urethritis  mild  treatment  may  be  directly  curative;  this 
cannot  be  said  of  the  gonococcic  type  of  the  disease.  Attention  to  genito- 
urinary hygiene,  regulation  of  the  diet,  the  administration  of  mild  laxa- 
tives, and  the  use  of  weak  astringent  injections  usually  cure  the  milder 
cases  within  a  few  da5^s;  at  least  such  measures  check  the  discharge.  Con- 
sidering the  causes  of  simple  urethritis,  it  is  obvious  that  surgical  treat- 
ment is  usually  necessary.  Thus,  dilation  or  cutting  operations  are  required 
for  stricture;  contracted  meatus  must  be  cut,  and  congested,  granular 
patches  treated  endoscopically,  or  other  measures  for  the  treatment  of 
chronic  organic  disease  of  the  urethral  canal  instituted. 

Simple  acute  urethritis  and  chronic  pathologic  conditions  of  the  canal 
are  so  intimatelv  associated  that  it  is  unnecessarv  to  discuss  further  the 


I 


SYSTEMATIC    TREATMENT    OF    UEETHEITIS.  139 

treatment  of  what  must  obviously  be,  in  the  majority  of  instances,  merely 
a  symptom. 

The  most  important  principle  in  the  management  of  severe  urethritis 
is  the  maintenance  of  physical  and  sexual  rest.  It  is  an  unfortunate  cir- 
cumstance that  individuals  with  gonorrhea  labor  under  the  fatuous  idea 
that  the  disease  is  not  serious.  It  is  consequently  usually  impossible  to 
induce  them  to  take  complete  rest.  They  wish  to  be  cured  promptly,  but 
upon  entirely  different  principles  from  those  applying  to  other  acute  in- 
flammations. A  patient  with  a  sharp  attack  of  urethritis  is  certainl}^  quite 
ill,  yet  he  can  seldom  be  induced  to  take  to  bed  and  be  treated  upon 
rational  principles.  A  man  with  a  fractured  limb  is  of  necessit}^  compelled 
to  rest,  and,  independently  of  the  mechanic  obstacle  to  movement,  it  is 
not  difficult  to  convince  him  that  absolute  quiet  is  necessary.  There  is 
little  or  no  danger  in  a  simple  fracture,  yet  the  patient  is  perfectly  tract- 
able. There  is  usually  great  danger  in  virulent  urethritis,  yet  it  is  sel- 
dom possible  to  convince  the  patient  of  the  fact. 

A  moment's  reflection  will  convince  the  reader  that  there  are  few  dis- 
eases characterized  by  so  many  and  so  severe  pathologic  possibilities  as 
gonorrhea.  Many  a  man,  crippled  at  middle  age,  and  who  is  ever  after 
afflicted  with  numerous  serious  bodily  infirmities,  owes  his  condition  to  an 
old-time  gonorrhea.  The  immediate  results  of  gonorrhea  are  often  severe. 
There  is  nothing  more  painful  than  an  attack  of  epididymitis:  a  disease 
that  may  produce  sterility,  and  in  certain  constitutions  may  lead  to  abscess 
or  gangrene  and  total  loss  of  the  testis.  This  complication  is  frequent. 
Prostatitis  and  cystitis,  of  acute  and  dangerous  forms,  are  occasional. 
Should  the  prostatic  urethra  become  involved,  it  is  a  fortunate  individual 
who  is  not  ever  thereafter  annoyed  with  vesical  irritability,  or  perhaps 
chronic  inflammation.  Stricture,  the  most  important  sequel  of  gonorrhea, 
is  often  productive  of  the  most  profound  pathologic  disturbances  in  the 
proximal  portion  of  the  genito-urinar}^  tract.  Inflammation  of  the  bladder, 
calculous  disease,  inflammation  and  dilation  of  the  ureters,  surgical  diseases 
of  the  kidney,  and  possibly  ordinary  Bright's  disease  are  often  directly  trace- 
able to  it.  Few  individuals  who  have  suffered  from  pronounced  stricture 
are  unaffected  either  with  renal  disease  or  what  is  practically  the  same  thing, 
a  locus  minoris  resisteniice  in  the  direction  of  the  kidneys  that  favors  the 
development  of  acute  or  chronic  Bright's  disease  from  apparently  trivial 
causes.  There  are  few,  if  an3^  cases  of  posterior  gonorrhea  in  which  the 
prostate  is  unaffected.  It  is  the  author's  view  that  many  individuals  who 
in  after-life  develop  prostatic  hypertrophy  owe  that  condition  to  the  effects 
of  an  early  gonorrhea.  Even  a  casual  survey  of  the  morbid  possibilities  of 
urethritis  convinces  one  that  it  is  a  formidable  disease.  Gonorrhea  is  the 
most  dangerous  of  the  venereal  disease,  for,  through  the  medium  of  its 
sequels  and  complications,  it  causes  more  deaths  than  syphilis.  By  com- 
parison, chancroid  is  benign.     Subtract  the  evil  effects  of  gonorrhea  from 


140  UEETHRITIS   AND    GONORKHEA. 

liuman  ills,  and  the  resulting  increase  in  human  longevity  and  happiness 
would  be  surprising. 

Every  patient  with  severe  urethritis  should  justly  be  confined  to  bed 
for  from  one  to  two  weeks.  If  this  were  practicable,  most  cases  would  not 
only  be  subdued  within  two  or  three  weeks,  but  complications  and  sequels 
would  be  rare,  providing  the  conjoined  treatment  were  not  injurious. 
Sexual  rest  is  a  sine  qua  non;  this  implies  both  mental  and  physical  sexual 
repose. 

Second  only  in  importance  to  rest  is  attention  to  diet.  A  restricted 
regimen  is  necessary,  not  only  because  of  its  antiphlogistic  effects,  but  to 
limit  the  waste-products  excreted  by  the  urine,  the  amount  and  character 
of  which  determine  the  irritating  properties  of  that  fluid.  There  is  noth- 
ing to  add,  in  this  connection,  to  the  remarks  made  in  Chapter  I. 

Water  in  large  quantity  is  especially  valuable  in  urethritis.  To  plain 
distilled  water  may  be  added  potassium  citrate,  acetate,  or  bicarbonate. 
Profuse  diuresis,  providing  the  urine  is  bland  and  non-irritating,  is  bene- 
ficial; the  diseased  urethra  requires  this  frequent  irrigation  for  the  removal 
of  infectious  secretions. 

Cleanliness  is  essential;  if  the  prepuce  be  long,  it  should  be  retracted, 
if  possible,  several  times  daily  and  the  glans  bathed  to  prevent  balanitis. 

The  dressing  of  the  penis  is  important.  Binding  absorbent  cotton  or 
other  material  over  the  meatus — a  plan  frequently  followed  by  patients 
with  a  long  prepuce — is  bad  practice.  Inasmuch  as  the  urethritis  is  pro- 
duced by  infection  of  successive  areas  of  mucous  membrane  with  pathog- 
enic germs,  the  process  extending  gradually  from  before  backward,  any 
dressing  that  dams  back  the  discharge  must  enhance  the  danger  of  exten- 
sion. Such  improper  dressing  may  cause  serious  complications.  A  simple 
plan  is  for  the  patient  to  roll  his  shirt  up  in  front  out  of  harm's  way  and 
pin  upon  the  tail  of  that  garment  a  soft  white  handkerchief  or  napkin;  this 
should  be  drawn  forward  beneath  the  perineum  and  up  over  the  penis  so 
that  one  corner  of  the  cloth  may  be  tucked  down  each  leg  of  the  trousers. 
The  penis  rests  in  the  folds  of  cloth,  the  meatus  being  unobstructed.  An- 
other plan  is  to  pin  the  toe  of  a  stocking  upon  the  drawers  in  such  a  manner 
that  the  penis  may  hang  therein,  without  the  meatus's  coming  in  contact 
with  the  improvised  bag.  In  the  bottom  of  this  receptacle  absorbent  cotton 
may  be  placed  and  frequently  changed.  There  are  several  cloth  gonor- 
rhea-bags upon  the  market  that  answer  the  same  purpose.  By  attention  to 
these  little  details  cleanliness  may  be  secured,  and  at  the  same  time  free 
drainage  of  the  affected  membrane  facilitated. 

One  of  the  best  measures  for  facilitating  resolution  of  inflammation  is 
the  application  of  heat,  and  it  is  nowhere  more  efficacious,  if  properly  ap- 
plied, than  in  inflammations  about  the  sexual  apparatus.  Heat  applied 
by  means  of  the  sitz-bath  of  from  a  half  to  one  hour's  duration  several  times 
daily  is  very  valuable,  particularly  if  there  is  irritation  about  the  prostate  or 


INTERNAL    MEDICATION    IN'    URETHRITIS.  141 

vesical  neck.  In  lieu  of  the  bath,  prolonged  soaking  of  the  penis  in  hot 
water  is  beneficial.  AVhen  urination  is  very  painful,  relief  may  be  obtained 
by  urinating  while  the  organ  is  immersed  in  hot  water. 

The  use  of  remedies,  both  internal  and  local,  should  be  guided,  not 
only  by  a  knowledge  of  the  natural  course  of  the  disease,  but  by  the  con- 
ditions prevailing  at  various  stages  of  the  affection  in  each  individual  pa- 
tient. It  would  be  absurd,  as  well  as  pernicious,  to  treat  a  case  complicated 
in  the  stationary  stage  by  inflammation  of  the  bladder  or  prostate  in  the 
routine  fashion  prescribed  for  the  average  uncomplicated  case  at  the  same 
period  of  the  disease.  It  is  to  be  remembered  that,  inasmuch  as  the  disease 
cannot  be  aborted  when  once  it  has  fairly  begun,  we  must  content  our- 
selves by  a  not  too  officious  management  of  the  case  until  the  normal  process 
of  repair  begins. 

Internal  Medication. — The  range  of  internal  medication  in  acute  ure- 
thritis is  not  very  extensive;  the  so-called  specific  remedies  especially  are 
limited  in  number.  During  the  increasing  stage  there  is  sometimes  con- 
siderable fever,  indicating  tincture  of  aconite,  veratrum  viride,  or  the  coal- 
tar  series.    These  remedies  are  not  used  sufficiently  often. 

Alkalies  should  be  given  throughout  the  disease,  either  alone  or  in 
combination  with  other  drugs.  The  fluid  extract  of  pichi  has  an  excellent 
effect  in  soothing  the  inflamed  mucous  membrane.  Infusions  of  buchu, 
slippery  elm,  uva  ursi,  linseed,  etc.,  are  all  beneficial.  The  ergots  of  rye 
and  corn  are  recommended  by  some  as  having  a  specific  effect.  In  the 
early  stages  ergot  does  not  seem  particularly  serviceable.  Later  on,  how- 
ever, it  has  an  astringent  effect.     It  should  be  given  in  liberal  doses. 

The  fluid  extract  of  corn-silk,  1  dram  every  two  or  three  hours,  has 
been  highly  recommended  in  acute  gonorrhea.  This  remedy  is  disappoint- 
ing in  acute  inflammation,  though  it  sometimes  seems  beneficial  in  chronic 
urethral  catarrh. 

Anaphrodisiacs  are  demanded  to  allay  sexual  excitement  and  for  their 
sedative  effect  upon  the  inflammation.  Thirty  to  60  grains  of  potassium 
or  sodium  bromid  at  bed-time  cause  usually  the  desired  effect.  The  follow- 
ing mixtures  are  serviceable: — 

I^  Fl.  ext.  ergotse m.  xv. 

Tr.  gelsemii m.  v. 

Potassii  bromidi gr.  xx. 

Tr.  hyoscyami m.  xxx. 

Syr.  aurantii q.  s.  ad  5ss. 

M.     Sig.:    At  bed-time. 

The  following  is  also  serviceable: — 

I^  Chloralis  hyd « gr-  v. 

Tr.  aconiti  rad m.  iij. 

Sodii  bromidi gr.  xxx. 

Aq.  camphorse q.  s.  ad  gss- 

M.     Siff.:    At  bed-time. 


142  UKETHEITIS   AND    GONOERHEA. 

Either  of  these  combinations  will  usually  prevent  or  relieve  chordee. 
Opiates  may  be  necessary,  however,  if  erections  are  frequent  and  painful. 
Opium  is  slightly  stimulating  to  the  sexual  organs;  this  detracts  somewhat 
from  its  efficacy  as  an  anodyne  in  these  cases.  This  may  be  counteracted 
by  combining  moderate  doses  of  tincture  of  opium  with  either  chloral  or 
potassium  bromid.  Where  drugs  fail,  the  cold-water  coil  will  afford  relief, 
and  in  addition  benefits  the  inflammation.  If  the  patient  sleeps  upon  a 
hard  bed,  with  a  knotted  towel  about  his  waist  so  that  he  cannot  com- 
fortably lie  upon  his  back,  painful  erections  are  not  so  apt  to  occur. 

Morphia  is  sometimes  necessary,  and  is  best  given  by  suppository,  plain 
or  in  the  following  combination: — 

IJ  Morph.   sulph gr.  V12  to  Vs- 

Ext.  hyoscyami gr.  ss. 

Butyii    cac q-  s. 

M.     Ft.  suppos.  No.  1. 

Sig. :    At  bed- time. 

The  various  balsamic  preparations  are  most  relied  upon  in  the  treat- 
ment of  gonorrhea.  These  should  not  usually  be  given  during  the  increas- 
ing stage;  more  benefit  is  to  be  derived  from  them  when  not  used  early. ^ 
There  is  no  objection  to  the  administration  of  sandal-wood  in  the  increas- 
ing stage;  cubebs  and  copaiba,  however,  are  more  stimulating,  and  not 
advisable  at  this  time.  Sandal-wood  oil  is  best  administered  in  capsules 
containing  from  10  to  15  minims.  Of  these,  from  four  to  ten  may  be  given 
daily.  The  pure  oil  may  be  given  in  doses  of  10  to  15  drops  upon  a  lump 
of  sugar,  four  or  five  times  daily.  The  limit  of  tolerance  is  sometimes 
indicated  by  gastric  disturbance;  more  frequently  by  backache  resembling 
lumbago,  this  being  probably  nephralgia  from  irritation  of  the  kidneys. 
Sandal- wood  is  more  likely  to  cause  this  than  are  copaiba  and  cubebs.  Dur- 
ing the  stationary  and  declining  stages  copaiba  and  cubebs  may  be  given. 
Of  the  two  drugs,  cubebs  is  more  stimulating  to  the  urethra,  but  least 
irritating  to  the  stomach.  Copaiba  occasionally  causes  an  unpleasant  ef- 
florescence or  rash  upon  the  skin,  sometimes  simulating  measles.  This 
eruption  sometimes  lasts  a  week  or  more,  as  illustrated  by  a  recent  case 
under  the  care  of  the  author's  assistant.  Dr.  Buell  S.  Rogers,  in  which  the 
eruption  lasted  two  weeks  after  cessation  of  the  drug.  The  reason  for  action 
of  copaiba  is  not  known.  The  eruption  is  probably  dependent  on  idiosyn- 
crasy, an  impression  being  made  upon  the  sympathetic  nervous  system 
analogous  to  that  produced  in  some  individuals  by  the  ingestion  of  shell- 
fish, overripe  tomatoes,  etc.  Quinin  and  numerous  other  drugs  sometimes 
produce  similar  eruptions,  probably  in  the  same  way.  Defective  renal  elimi- 
nation and  vicarious  skin  action  may  possibly  explain  these  cases. 


^  The  recent  dicta  of  some  of  our  genito-urinary  surgeons  to  the  eflfeet  that  the 
balsams  are  practically  useless  in  gonorrhea  cannot  be  accepted  by  observant  clinicians. 


IXTEEXAL    MEDICATIOX    IN    UEETHRITIS.  143 

Ciibebs  and  copaiba  may  be  given  in  doses  of  10  to  20  drops  of  the 
oil  four  to  five  times  daily,  either  in  capsules  or  emulsion.  The  emulsion 
is  preferable  where  the  patient  does  not  object  to  it.  The  doses  of  the 
balsams  may  be  increased  to  the  limit  of  tolerance.  They  should  be  given 
more  liberally  as  the  inflammation  declines.  The  following  balsamic  emul- 
sions are  excellent: — 

IJ  Liq.   jDotassae    3j. 

Bals.  copaibae Bj- 

01.  gaultherise m.  x. 

Ext.  glycyrrhizse  fl Sss. 

Saccharini   q.  s. 

Muc.    acacia? q.  s.  ad  ^iv. 

M.     Sig. :    A  teaspoonful  every  two  or  three  hours. 

I^  01.  cinnamomi m.  x. 

01.  cubebse, 

Sp.  aether,  nit of  each  §ss. 

Muc.  acaeiae q.  s.  ad  §viij. 

31.     Sig.:    A  tablespoonful  three  or  four  times  daily. 

Cubebs  may  be  given  in  powder  in  doses  of  1  dram  two  or  three  times 
daily;  this  sometimes  agrees  with  the  stomach  better  than  either  the  emul- 
sion or  capsule.  The  formulas  given  are  merely  illustrative.  Vidal  ad- 
vocates the  use  of  gurjun  balsam  in  doses  of  2  grams  before  each  meal. 
Taylor  recommends  the  tincture  of  cannabis  sativa,  10  to  15  drops  in  water 
three  or  four  times  daily.  In  the  later  stages  of  urethritis,  where  there  is 
a  tendency  to  chronicity,  turpentine  is  occasionally  of  value,  the  white  or 
Canada  turpentine  being  best. 

If  the  patient  is  debilitated  the  addition  of  iron  to  the  balsamic  prep- 
arations is  advisable  for  its  tonic  and  astringent  effect.  Matico  and  other 
vegetable  preparations  containing  tannin  are  recommended  for  internal  ad- 
ministration, but  their  efficacy  is  doubtful,  with  the  possible  exception  of 
hydrastis  Canadensis;    this  has  seemed  serviceable  in  some  chronic  cases. 

The  beneficial  effect  of  the  balsams  is  peculiar.  When  applied  locally 
by  injections  they  have  apparently  no  action  whatever.  It  would  appear 
that  in  their  passage  through  the  digestive  tract  and  circulation  into  the 
urine  they  undergo  some  chemic  change  by  virtue  of  which  they  exert  a 
special  soothing  effect  upon  the  inflamed  mucous  membrane.  That  they 
exert  any  specific  (microbicidal)  influence  in  gonorrhea  is  improbable. 
Their  effect  is  certainly  not  constitutional;  they  are  useless  in  gonorrhea 
in  the  female  unless  the  urethra  is  involved.  It  may  be  mentioned,  how- 
ever, that  copaiba  has  been  recommended  for  local  use  in  vaginitis.  Bara- 
tier^  recommends  copaiba  in  vaginal  suppositories  for  gonorrhea  in  women. 

Eaquin,  of  Paris,  has  prepared  a  solution  that  he  terms  "copaibate  of 


M.  Baratier :    "These  de  Paris.' 


1^:4:  UEETHEITIS    AXD   GONOREHEA. 

soda/"'  which  is  said  to  be  useful  as  an  injection  as  well  as  internally.  Salol 
and  eucalyptus  in  combination  are  often  serviceable  internally  in  ure- 
thritis. Salol  should  be  given  in  doses  of  from  10  to  20  grains,  with  10 
minims  of  eucalyptus  three  or  four  times  a  day.  The  benzoate  of  soda 
sometimes  acts  better  than  other  alkalines.  Pichi  and  saw  palmetto  are  oc- 
casionally beneficial. 

Aperient  medicines  are  always  useful  in  urethritis,  particularly  during 
the  acute  stage.  Saline  laxatives  are  especially  beneficial,  the  various 
natural  mineral  waters,  notably  the  Apenta  water,  being  excellent.  The 
Carlsbad  salts  are  also  of  service.  Constipation  is  invariably  attended  by 
prostatic  congestion,  and  possibly  urethral  also;  its  correction  is  therefore 
desirable.  Bruising  of  the  prostate  during  a  difficult  stool  may  be  the 
point  of  departure  for  prostatic  complications. 

Naphthol  has  recently  been  recommended  in  urethritis.  It  is  said 
to  become  decomposed  into  some  modification  of  phenol  (carbolic  acid), 
which,  passing  with  the  urine,  destroys  the  germs.  The  dosage  is  from  2 
to  15  grains  several  times  daily.  Naphthol  appears  to  be  indicated  in 
chronic  cystitis  rather  than  in  urethritis,  inasmuch  as  it  probably  makes  the 
urine  less  putrescible.  It  is  likely  to  disturb  the  stomach,  and,  as  gonor- 
rhea is  an  active  mixed  infection  rather  than  a  septic  process,  its  advantages 
are  doubtful.     Eucalyptus  fulfills  the  same  indication  and  is  more  reliable. 

Local  Medication. — Local  medication  in  acute  urethritis  may  be  accom- 
plished by  means  of  injections.  This  method  cannot  be  thrown  aside,  for 
not  all  patients  can  afford  the  time  and  money  required  for  systematic  irri- 
gation. 

Much  discussion  has  been  evoked  regarding  the  injection  method. 
There  is  a  deep-groimded — and  in  many  instances,  it  must  be  confessed, 
justifiable — prejudice  against  its  use  entertained  by  a  certain  proportion  of 
the  lait}^,  and  incidently  by  many  surgeons.  It  has  been  claimed  that  in- 
jections are  usually  responsible  for  stricture  and  other  complications  and 
sequels  of  urethritis.  This  prejudice  is  undoubtedly  well  founded  in  some 
instances;  yet  it  is  the  abuse,  and  not  the  use,  of  injections  that  is  re- 
sponsible for  their  unpleasant  results.  Injections  of  pure  water,  if  im- 
properly used,  may  produce  injury,  and  it  is  certain  that  unreasonably- 
strong  astringents  or  antiseptics  will,  as  a  rule,  prove  injurious.  Any  in- 
jection that  produces  severe  pain  is  strong  enough  if  repeatedly  used  to 
destroy  the  already  partially  devitalized  epithelium  of  the  mucous  mem- 
brane. As  a  consequence,  there  must  necessarily  occur  at  various  points 
localization  and  intensification  of  the  inflammation.  Injections  properly 
given  are  not  only  harmless,  but  often  beneficial.  They  are  really  proph- 
ylactic of  stricture  and  other  complications  by  limiting  the  severity  and 
duration  of  the  inflammation.  Any  form  of  injection  given  for  tbe  pur- 
pose of  Jugulating  the  disease  during  the  height  of  the  inflammation  is 
apt  to  produce  injurious  results.     It  is  unfortunate  that  many  surgeons 


LOCAL    MEDICATION    IN    UEETHKITIS.  145 

have  joined  in  the  popular  prejudice  against  injections.  The  average  pa- 
tient wlio  has  stricture  resulting  from  a  gonorrhea  that  has  been  treated 
])y  injections,  no  matter  how  skillfully  and  beneficially,  attributes  his  con- 
<lition  to  the  treatment.  Should  he  consult  a  surgeon  of  anti-injection  pro- 
clivities, his  erroneous  ideas  are  confirmed,  much  to  the  detriment  of  the 
reputation  of  his  former  surgeon,  who  perhaps  treated  the  patient  scien- 
tifically and  conservatively. 

An  important  feature  of  the  injection  method  is  the  selection  of  a  proper 
syringe.  Ordinary  syringes  with  long  nozzles  are  responsible  for  many 
cases  of  chronic  urethritis.  Their  introduction,  even  when  carefully  done, 
excites  more  or  less  mechanic  irritation.  It  is  not  unusual  to  detect  in 
long-standing  cases  a  congested  and  granular  patch  of  mucous  membrane 
at  the  point  where  the  nozzle  of  the  syringe  impinges  during  injection. 
Few  surgeons  devote  much  attention  to  the  instruction  of  the  patient  in 
the  proper  use  of  the  syringe  or  to  the  selection  of  a  j)roper  instrument. 
Xot  a  few  cases  of  chronic  urethritis  will  subside  immediately  upon  dis- 
carding faulty  syringes.  A  cure  may  result  from  the  use,  with  a  proper 
syringe,  of  astringent  solutions  that  have  been  worse  than  useless  when 
injected  through  one  of  the  long-nozzled  abominations.     The  best  form 


Fig.  39. — Proper  form  of  urethral  syringe.      (Capacity  5ss.) 


of  syringe  is  that  with  a  conic  point,  known  as  the  "Excelsior  P."  The 
instrument  should  be  of  some  capacity.  If  it  does  not  contain  sufficient 
fluid  to  thoroughly  distend  the  urethra  when  slowly  injected  with  moderate 
force,  the  medicament  does  not  come  in  contact  with  the  entire  diseased 
surface.  The  patient  should  first  urinate,  thus  removing  the  purulent 
secretion.  The  fluid  should  then  be  injected  slowly  and  steadily.  Too 
great  or  spasmodic  pressure  may  take  the  cut-off'  muscle  by  surprise,  and 
drive  the  fluid — and  with  it  germ-infection — into  the  deep  urethra,  pro- 
ducing prostatic,  vesical,  or  testicular  complications. 

During  the  increasing  stage  of  urethritis  injections  should  usually  be 
dispensed  with;  if  used  at  all,  they  should  be  very  mild.  A  solution  of 
potassium  permanganate  1-5000  or  mercury  bichlorid  in  a  strength  of  from 
1-30,000  to  1-15,000  is  about  the  best  routine  injection  for  use  at  this  period. 
Some  cases  are  materially  benefited  by  injections  at  this  time;  in  most  in- 
stances, however,  they  are  irritating.  Even  where  the  injection  seems  bene- 
ficial it  may  lose  its  effect  in  a  few  days,  when  it  becomes  necessary  to  super- 
sede it  by  some  of  the  ordinary  astringents  in  mild  solution. 

Good  judgment  is  necessary  in  using  astringents.  They  frequently 
prevent  the  normal  evolution  of  urethritis  by  condensing  the  tissues  and 
damming  up  the  natural  avenues  of  germ-elimination. 


146  TEETHEITIS    AXD    GOXOEKHEA. 

In  lieu  of  the  above  injections  during  the  increasing  stage  anodj'ne 
injections  may  he  given,  the  following  being  useful  formulas: — 

B  Atropise  sulph gr.  ij- 

Bismuthi  subnit 3iv. 

Muc.  acacise, 

Aq.  dest of  each  Bij. 

M.     Sig. :    Shake  Avell  and  inject  three  times  daily. 

IJ  Tr.  opii  deod 3ij. 

Bismuthi  subnit 3iv. 

Muc.  acacise, 

Aq.  dest of  each  gij. 

M.     Sig.:    Shake  well  and  inject  three  times  daily. 

IJ.  Morph.  sulph gr.  viij. 

Cocain  mur gr.  i j . 

Muc.  acacise 5j- 

M.     Sig.:    Inject  three  times  daily. 

A  mild  and  sedative  astringent  may  be  combined  with  the  anodynes: — 

IJ  Plumbi  acetatis gi'-  iv. 

Vini  opii 3ij . 

Aq.  rosge q.  s.  ad  Biv. 

M.     Sig.:    Inject  three  times  daily. 

I^  Sodii  biboratis gr.  xx. 

Morph.  sulph gr.  vj. 

Aq.  rosse Biv. 

M.     Sig.:    Inject  three  times  daily. 

In  the  stationary  stage  the  strength  of  astringent  injections  may  be 
slightly  increased.  It  seems  that  it  is  not  so  much  the  form  of  astringent 
as  the  method  of  its  use  that  determines  the  beneficial  efEects.  Many 
astringents  act  about  the  same  when  properly  used,  although  in  some  case? 
it  is  necessary  to  vary  them.  The  most  popular  astringent  is  zinc  sulphate. 
This  is  quite  uniformly  beneficial.  The  author  prefers  zinc  sulphocar- 
bolate  or  iodid.  Silver  nitrate  in  a  strength  of  ^/g  to  V2  grain  to  the 
ounce  of  water  is  often  serviceable.  Some  recommend  it  as  the  best  routine 
injection. 

The  following  are  illustrative  astringent  combinations: — 

I^  Zinci  sulphat.   (or  acetat.) gr.  xij. 

Morph.    sulph gr.  x. 

Glycerini   §j. 

Aq.  rosse Biij- 

M.     Sig.:    Injection. 

IJ  Zinci  sulphocarb gr.  xvj. 

Glycerini §j . 

Aq.   rosse giij. 

M.     Sig.:    Injection. 


FOEMULAS    FOR    IXJECTIOXS.  147 

I^  Zinci  iodidi gr.  viij. 

Ac.  earbol gr-  iv. 

Aq.  dest §iv. 

M.     Sig. :    Injection. 

IJ  Plunibi  acet gr.  xx. 

Tr.   opii    3ij . 

Aq.  rosse q.  s.  ad  §iv. 

M.     Sig.:    Injection. 

Vegetable  astringents  are  often  preferable  to  mineral.  Matico,  hy- 
drastis,  catechn,  kino,  and  the  like  are  very  popular;  their  efficacy  depends 
upon  the  tannic  acid  they  contain.  The  muriate  of  hydrastin  is  very  effi- 
cacious. An  excellent  vegetable  astringent  is  the  fluid  extract  of  hamamelis 
Virginica.     The  following  formula  is  very  serviceable: — 

Ijl  Hydrastin  niur gi"-  x. 

Ext.  hamamelis  fl. 3ij. 

Glycerini   §ss. 

Aq.   dest q.  s.  ad  §iv. 

M.     Sig.:    Injection. 

As  the  inflammation  subsides  the  strength  of  injections  may  l)e  in- 
creased. This  should  be  cautiously  done,  however;  in  no  instance  should 
an  injection  that  jDroduces  considerable  pain  be  continued.  Nothing  more 
than  slight  smarting  is  warrantable.  In  some  cases  the  injection  does  not 
produce  much  immediate  discomfort,  but  smarting  during  micturition  in- 
creases. Vnder  such  circumstances  either  the  strength  of  the  injection 
should  be  diminished  or  some  other  form  substituted.  This  is  especially 
pertinent  to  injections  of  mercury  bichlorid.  In  using  this  drug  in  a 
strength  of  even  V^g  grain  to  the  ounce  patients  will  often  complain,  in  a 
day  or  two,  of  severe  smarting  in  micturition. 

Thallin  sulphate  is  often  of  service  in  a  strength  of  20  grains  to  the 
ounce  of  rose-water. 

Iodoform  emulsion  has  been  used  in  acute  urethritis,  but  it  does  not 
seem  so  efficacious  as  many  other  drugs.  In  chronic  urethritis,  however, 
it  may  be  used  Avith  advantage  if  the  patient  does  not  object  to  its  tell- 
tale odor. 

Various  new  preparations  of  silver  are  becoming  quite  popular  in  the 
treatment  of  urethritis.  There  is  a  growing  conviction  that  silver  is  the 
coming  antiseptic  par  excellence.  It  is  too  early,  as  yet,  to  decide  positively 
as  to  the  merits  of  the  new  preparations;  but,  so  far  as  the  author's  ex- 
perience has  gone,  they  are  very  valuable.  Injections  of  argonin,  begin- 
ning with  2  per  cent,  and  increasing  gradually  up  to  8  or  even  10  per  cent., 
often  act  splendidly.  Protargol  in  Vo-per-cent.  solution  appears  to  be  less 
irritating  and  quite  as  reliable.  Xargol,  a  new  combination  of  silver  and 
nucleins,  merits  a  trial.  Mercurol,  the  latest  mercurial  antiseptic,  seems 
promising. 


148  UEETHEITIS    AND    GOXOREHEA. 

Soluble  bougies  of  various  types  of  medication  have  been  used  in  acute 
urethritis.  This  method  of  treatment  is  not  only  illogical,  but  injurious. 
Suppositories  of  sufficient  stiffness  to  permit  their  introduction  into  the 
urethra  will  produce  mechanic  irritation.  There  is  also  no  form  of  soluble 
bougie  that  can  be  practically  applied  by  the  majority  of  patients.  There 
is,  also,  danger  of  exciting  inflammation  of  the  deep  urethra.  The  author 
has  seen  a  number  of  cases  of  prostatic  and  vesical  complications,  in  con- 
sultatio]!,  apparently  attributable  to  the  use  of  the  bougies,  and  in  experi- 
menting with  them  in  his  own  practice  he  has  had,  on  several  occasions, 
disagreeable  results.  It  is  impracticable  to  combine  germicide  drugs  with 
the  bougies  in  sufficient  strength  to  destroy  gonococci,  and,  as  the  l^ougie 
necessarily  carries  with  it  more  or  less  infectious  material  into  the  deeper 
])ortion  of  the  canal,  extension  of  iniiammation  is  to  be  expected.  In  chronic 
urethritis  the  l)0ugies  are  often  of  service.  Even  here,  however,  they  benefit 
chiefly  tlirough  a  primary  increase  of  irritation  produced  by  mechanic  stimii- 
lation. 

One  of  the  most  recent  methods  of  treatment  of  urethritis  is  by  retro- 
jection  of  hot  water  or  antiseptic  solutions  through  a  soft-rubber  catheter 
or  some  specially-devised '  mechanic  contrivance.  Many  who  have  tried 
this  metliod  are  very  enthusiastic  in  its  praises,  but  the  author  is  free  to 
say  that  they  must  either  have  a  knack  in  the  application  of  the  method 
wliich  he  has  been  unable  to  acquire  or  his  patients  are  characterized  by 
very  sensitive  urethras.  The  method  is  open  to  the  same  objections  as  the 
use  of  soluble  bougies.  In  introducing  the  tube  more  or  less  secretion  is 
carried  into  the  deeper  parts,  and  tlie  injection  fluid  cannot  be  safely  given 
in  strength  sufficient  to  neutralize  it.  More  or  less  mechanic  irritation 
results,  and  in  acute  cases  this  is  injurious.  On  the  other  hand,  in  cases 
that  tend  toward  chronicity  the  method  is  useful. 

A  soft,  open-ended  catheter  is  better  than  special  tubes  for  deep  ure- 
thral irrigation  under  ordinary  circumstances;  and  always  better  in. the 
anterior  urethra.     The  short  nozzle  with  hydrostatic  jDressure  is  best  of  all. 

A  recent  fad  in  the  treatment  of  urethritis  is  "the  dry  method'':  the 
introduction  of  dry  antiseptic  powders  into  the  canal  through  a  special 
and  patented  device.  In  acute  cases  this  method  is  open  to  the  same  ob- 
jections as  are  soluble  bougies  and  retro-irrigation.  It  may  be  of  service, 
however,  in  chronic  urethritis. 

Blistering  the  perineum  and  penis  is  a  popular  remedy  for  acute  gonor- 
rhea with  some  surgeons.  Milton,  in  particular,  favors  this  method  of 
treatment;  he  applies  eantharidal  plaster  wrapped  about  the  penis.  Most 
patients  object  to  fly-blisters,  and  compromise  is  often  necessary.  Tincture 
of  iodin  applied  along  the  course  of  the  urethra  frequently  benefits.  Mil- 
ton also  recommends  what  he  terms  a  "caustic  plug"  in  obstinate  gonor- 
rhea. A  strip  of  linen,  saturated  in  5-grain  solution  of  silver  nitrate,  is 
inserted  into  the  urethra  through  an  endoscopic  tube;    the  latter  is  then 


CHRONIC    UEETHEITIS.  149 

rtmovtHl  and  the  cloth  allowed  to  remain  until  it  comes  away  with  the 
urine. 

AVhere  practicable  to  employ  it,  the  permanganate-irrigation  method 
is  best  of  all  in  the  treatment  of  subacute  cases  and  acute  cases  in  the  de- 
clining stage. 

It  is  not  the  author's  intention  to  attempt  to  pre&ent  all  the  various, 
methods  of  treatment  and  specifics  recommended  for  urethritis.  This  would 
l)e  an  onerous  as  well  as  unprofitable  task.  The  list  of  ''specifics''  recom- 
mended runs  well  into  the  hundreds.  What  has  been  said  is  intended  only 
as  a  practical  outline  of  the  therapeutics  of  acute  urethritis,  upon  Avhich 
tlie  practitioner  can  build  as  his  experience  may  suggest. 

Chronic  Urethritis. — Chronic  urethritis  embraces  all  phases  of  se- 
cretion-forming inflammations  of  the  urethra  generally  included  under  the 
generic  term  of  gleet.  The  latter  term — if  used  at  all — should  be  applied 
with  the  understanding  that  it  merely  implies  a  symptom. 

Causes. — The  causes  of  chronic  urethritis  are  as  follow: — 
1.  Idiosyncrasy.     This  consists,  in  this  instance,  of  a  predisposition 
to  mucous  fluxes  and  catarrhs  characterizing  certain  individuals.     This  is 
a  particularly  important  factor  in  certain  climates.     The  variable  tempera- 
ture and  barometric  pressure  of  our  lake-region  are  an  illustration  of  this. 
3.  The  gouty  and  rheumatic  diatheses. 

3.  Dyscrasias  of  various  kinds,  particularly  syphilis. 

4.  Cachectic  conditions  due  to  various  constitutional  diseases,  acute 
or  chronic. 

5.  Intemperance,  dietetic  and  alcoholic. 

6.  Improper   treatment,   usually   involving   too    powerful    injections, 
with  destruction  of  epithelium. 

7.  Too  active  exercise  during  the  acute  stage. 

8.  Prolonged  and  ungratifled  sexual  desire. 

9.  Sexual  excesses  and  masturljation. 

10.  Privation  and  unhealthful  environment. 

11.  Localization  of  acute  inflammation,  with  resulting  chronic  local  dis- 
ease; e.g.,  stricture  or  granular  and  congested  areas — the  most  important 
factor  of  all. 

Varieties. — Chronic  urethritis  presents  tliree  forms: — 

1.  The  acute  inflammation  subsides,  but  remains  subacute,  with  occa- 
sional acute  exacerbations  accompanied  by  thick,  purulent  discharge. 
There  is  continual  discomfort,  with  more  or  less  pain  and  smarting  on 
urination.  Generally,  too,  the  prostate  is  involved  to  a  certain  extent, 
causing  a  feeling  of  fullness  and  tension  in  the  perineum,  with  frequent 
urination. 

2.  The  discharge  becomes  thin  and  watery,  being  sometimes  so  scanty 
that  nothing  is  visible  save  a  drop  or  two  of  muco-purulent  fluid  in  the 
morning.     This  is  the  most  frequent  form,  and  is  not  usually  attended  by 


150  UEETHRITIS    AND    GONORRHEA. 

anything  but  psychic  discomfort.  It  may  depend  npon :  (a)  Simple  catarrh, 
involving  constitutional  and  local  predisposition,  (b)  Congested  and  gran- 
ular patches  of  mucous  membrane,  (c)  Organic  stricture,  (d)  Urethral 
polypi  and  papillomata;  these  are  rare,  but  such  cases  are  reported  by  Griiu- 
feld  and  others  and  the  author  has  operated  several  times  for  urethral  papil- 
(lomata,  with  a  resulting  cure  of  obstinate  gleet,  (e)  Abscesses  or  fistulas 
resulting  from  acute  urethritis  and  becoming  chronic,  (f)  Dilation  and 
pocketing,  with  chronic  inflammation  of  the  lacuna  magna,  (g)  Urethro- 
prostatic  catarrh,  (h)  Posterior  urethritis, — i.e.,  chronic  follicular  prostati- 
tis. (/)  Urethral  folliculitis.  (/)  Cowperitis.  (/<■)  Tubercular  infection.  (/) 
Seminal  vesiculitis. 

3.  A  form  of  chronic  urethritis  in  which  there  is  apparent  recovery. 
After  a  variable  period  of  time  a  thin,  muco-purulent  discharge  develops, 
as  a  consequence  of  sexual  excesses  or  intemperance. 

The  distinctive  features  of  chronic  urethritis  depend  upon  differences 
in  degree  of  activity  of  inflammation.  Such  difl'erences  do  not  warrant 
a  distinct  differentiation  of  chronic  urethritis  and  gleet.  As  a  rule,  the 
danger  of  contagion  is  directly  proportionate  to  the  degree  of  purulency  of 
the  discharge.  It  is  possible,  however,  that  the  discharge  of  gonococcic 
urethritis  may  lose  its  properties  of  pus  and  specific  infection,  and  yet  be 
capable  of  causing  various  uterine,  periuterine,  salpingian,  and  ovarian 
troubles  by  virtue  of  the  toxins  it  contains. 

So-called  gleet  often  consists  in  the  appearance,  under  sexual  excite- 
ment and  on  rising  in  the  morning,  of  a  slight,  sticky  moisture  at  the 
meatus.  In  most  of  these  cases  the  annoyance  is  entirely  mental.  The 
appellation  of  "psychic  gleet,"  although  a  little  far-fetched,  would  not  be 
inappropriate  in  some  of  these  cases.  In  some  instances  the  patient  can- 
not detect  the  secretion,  save  by  squeezing  the  urethra.  Some  patients 
would  really  experience  disappointment  if  the  morning  "tear"  of  urethral 
secretion  should  chance  to  be  absent.  The  vigor  and  pertinacity  with  which 
they  "milk"  the  urethra  to  obtain  the  melancholy  satisfaction  of  exhibiting 
a  drop  or  two  of  mucus  in  evidence  of  their  alleged  deplorable  condition 
is  worthy  of  a. better  cause.  In  probably  50  per  cent,  of  these  cases  the 
discharge  is  kept  up  by  this  practice.  Such  persons  will  usually  acknowl- 
edge the  habit  of  seeking  for  the  discharge  a  number  of  times  daily.  They 
are  surprised  when  informed  that  their  enthusiastic  search  for  something 
they  do  not  wish  to  find  is  mainly  responsible  for  their  woes.  The  patho- 
logic condition  in  these  cases  is  simple  hypersecretion  of  mucus  by  the  over- 
worked urethral  follicles.  Quite  a  proportion  of  cases  in  which  discharge 
is  more  abundant  are  dependent  upon  urethral  catarrh,  with  coincident 
hypersecretion  of  mucus  due  to  (1)  habitual  overstimulation  of  the  glands; 
(2)  their  enlargement. 

The  discharge  is  usually  thin,  watery,  and  of  a  whitish  color.  It  be- 
comes thick  and  yellowish,  however,  on  the  supervention  of  the  various 


CHKOA'IC    URETHRITIS. 


151 


causes  enumerated  in  the  etiology  of  chronic  urethritis.  A  patient  suf- 
fering with  gleet  is  continually  liable  to  acute  exacerbations  of  urethritis 
from  slight  cause.  The  chief 
source  of  discharge  is  the 
mucous  follicles  of  the  por- 
tion of  the  urethra  involved 
in  the  chronic  inflammation 
and  the  abraded  epithelium. 
The  discharge  contains  more 
or  less  epithelium.  One  of 
the  characteristic  features  of 
gleet  is  rapid  formation  and 
removal  of  the  delicate  ure- 
thral epithelial  cells.  This 
especially  applies  to  cases  of 
chronic  inflammation  de- 
pendent upon  such  chemic 
or  traumatic  causes  as  strong 
injections  and  injudicious  in- 
strumentation. If  congested, 
granular,  or  abraded  patches 
exist,  there  is  constant  hyper- 
secretion of  mucus  or  muco- 
pus,  with  exfoliation  of  epi- 
thelium. Here,  the  current 
of  urine,  passing  over  the  dis- 
eased surface,  rolls  up  into 
stringy  shreds  the  desqua- 
mated epithelium  and  muco- 
purulent deposit  that  coats 
the  diseased  area.  These 
strings  appear  floating  in  the 
urine  as  delicate  filaments — 
t ripper -fdden  —  that  invari- 
ably indicate  urethral  disease. 
This  appearance  of  the  urine 
is  usually  attributed  to  strict- 
ure. This  is  .a  mistake;  it  is 
often  observed  where  strict- 
ure is  absent,  being  due  to 
urethral  catarrh  and  general 
desquamation  of  epithelium. 
Chronic  inflammation  exists  posterior  to  stricture.  Obstruction  to  the 
escape  of  urine  at  this  point  causes  more  or  less  pouching  of  the  urethra 


Fig.  40. — Chronic  granular  urethritis. 
(After  Finger.) 


152  UEETHEITIS    AXD    GOXOEKHEA. 

behind  it.  The  dilated  part  loses  its  elasticity  and  contractility;  as  a  con- 
sequence, a  somewhat  passive  pouch  forms  upon  its  floor,  in  which  a  drop 
or  two  of  residual  urine  is  almost  invariably  found.  Decomposition  occurs, 
enhancing  the  inflammation  and  consequent  muco-purulent  secretion. 
From  this  point  the  gleety  discharge  and  thready  urinary  filaments  char- 
acterizing stricture  are  derived. 

The  author  desires  to  emphasize  particularly  the  importance  of  pow- 
erful injections  in  the  etiology  of  chronic  urethritis.  The  obstinacy  of 
some  cases  is  undoubtedl}^  dependent  upon  chemic  destruction  of  the  ure- 
thral epithelium.  Frequent  repetitions  of  this  eventually  result  in  an 
abraded  condition  of  the  entire  mucous  membrane,  necessitating  rapid 
proliferation  of  epithelium  for  rejDair.  This  epithelium,  however,  is  of  low 
grade,  and,  being  largely  governed  by  physiologic  habit,  is  thrown  off  as 
rapidly  as  formed.  As  a  result,  the  canal  is  perpetually  raw  and  inflamed. 
Injections  that  are  strong  enough  to  accomplish  this  untoward  result  are 
not  necessarily  acutely  painful. 

IntemjDerance  and  faulty  sexual  hj-giene  are  perhaps  the  most  impor- 
tant of  all  etiologic  factors  in  chronic  urethritis. 

The  ingestion  of  alcohol  predisposes  all  tissues  to  inflammation;  this 
is  especially  true  of  mucous  membranes.  Alcohol  has  also  a  special  effect 
in  overstimulating  the  sexual  apparatus,  not  only  through  the  nervous 
system,  but  more  directly  by  imparting  irritating  properties  to  the  urine. 

Most  patients  with  urethritis  are  more  disturbed  by  the  interruption 
of  fornication  than  by  any  inconvenience  or  danger  incidental  to  the  dis- 
ease. They  also  have  the  fatuous  idea  that  sexual  stimulation  short  of 
actual  intercourse  is  not  injurious;  as  a  consequence,  they  associate  in- 
timately with  loose  women,  thus  keeping  the  sexual  system  in  a  constant 
state  of  excitement.  This  is  as  disastrous  as  sexual  indulgence,  if  not 
worse.  So  soon  as  discharge  has  ceased — in  many  instances  so  soon  as  it 
has  greatly  diminished — sexual  indulgences  are  begun.  Patients  come  to 
the  surgeon  in  the  fault-finding  manner  of  the  average  venereal  patient, 
and  ascribe  the  unfavorable  progress  of  the  urethritis  to  improper  treat- 
ment; seldom  will  they  acknowledge  sexual  excitement  or  indulgence  or 
the  use  of  stimulants.  Were  it  not  for  the  sexual  and  alcoholic  elements 
in  the  production  of  chronic  inflammation  our  results  would  not  be  so  un- 
satisfactory. 

A  lack  of  rest  is  another  important  factor  in  chronic  urethritis.  In 
every  case  of  virulent  inflammation  in  which  the  patient  is  compelled  to  be 
on  his  feet  most  of  the  time,  or  to  indulge  in  muscular  strains,  lifting,  etc., 
we  may  expect  the  disease  to  be  stubborn.  Patients  enjoying  facilities  for 
comparative  quiet  will  recover  promptly  in  the  majority  of  instances. 

Duration. — The  duration  of  chronic  urethritis  is  indefinite.  It  de- 
pends mainly  upon  the  curability  of  the  pathologic  changes  in  the  canal 
to  which  the  perpetuation  of  inflammation  is  due.     In  some  instances  a 


TEEATMEXT    OF    CHEOXIC    UEETHEITIS. 


153 


complete  cure  is  apparently  impossible;  cases  are  encountered  that  have 
resisted  for  years  every  known  method  of  treatment. 

Some  cases  of  alleged  gieet  cannot  be  cured  because  of  the  psychopathic 
state  of  the  patient.  There  are  numerous  cases  in  which  the  patient  is 
practically  cured^  but  in  which  it  is  impossible  to  convince  him  that  such 
is  the  case.  These  cases  of  psychopathic  gleet  go  from  surgeon  to  surgeon, 
vainly  seeking  a  cure  for  something  that  does  not  exist. 

One  of  the  most  interesting  of  modern  discoveries  is  the  relation  of 


Fig.  41. — Guyon's  bulbous  "bougie  exploratrice." 

chronic  seminal  vesiculitis  and  follicular  ^prostatitis  to  chronic  urethral  dis- 
charges. Mr.  Jordan  Lloyd,  of  Birmingham,  England,  was  perhaps  the 
first  to  call  attention  to  the  former  condition,  and  should  be  given  due  credit. 
The  treatment  of  these  conditions  will  receive  attention  later. 

Too  prolonged  and  energetic  treatment  is  often  responsible  for  the 
perpetuation  of  gleet.  Cases  are  observed  in  which  improvement  occurs 
only  upon  complete  cessation  of  treatment. 

Cases  of  undoubted  chronic  urethritis  are  occasionally  seen  that  defy 
all  measures  of  treatment. 

Treatment. — The  treatment  of  chronic  urethritis  rec[uires  more  or  less 


Fig.  42. — Lamp  for  direct  electric  illumination  of  the  urethra. 

radical  measures  and  a  variety  of  remedies,  these  being  necessitated  by  the 
varying  character  of  the  special  causes  perpetuating  the  inflammation. 

The  urethra  should  first  be  explored,  to  determine,  if  possible,  the 
particular  lesion  that  is  keeping  up  discharge.  The  bulbous,  flexible  French 
bougies  will  usually  be  found  quite  satisfactory  for  this  purpose.  In  the 
majority  of  instances  the  discovery  of  stricture  or  a  localized  spot  of  in- 
flammation is  all-sufficient,  ocular  inspection  being  of  little  or  no  advantage. 


154 


UEETHEITIS    AXD    GONOEEHEA. 


In  expert  hands  the  bulbous  bougie  determines  the  condition  of  the  ure- 
thra with  sufficient  accuracy.  Otis^s  acorn-tipped  metallic  sounds  may  be 
used,  but  soft  instruments  are  preferable. 

The  endoscope  (Figs.  43  and  44)  sometimes  bears  a  somewhat  similar 
relation  to  urethral  exploration  that  the  stethoscope  does  to  the  diagnosis  of 
thoracic  disease.  The  expert  in  physical  diagnosis  finds  the  unaided  ear 
usually  sufficient  for  exploration  of  the  chest,  the  stethoscope  becoming 
necessary  only  in  very  obscure  cases  or  those  in  which  critical  and  hair- 
splitting differentiation  of  objective  signs  is  desired.     Xumerous  elaborate 


Fiff.  43. 


endoscopes  have  been  devised,  but  for  practical  purposes  ordinary  straight, 
hard-rubber  or  silver  tubes,  with  a  strong  light  reflected  from  a  laryngo- 
scopic  reflector  or  from  one  of  the  modern  small  reflecting  electric  lamps, 
are  satisfactory.  It  is  well  to  have  a  series  of  tubes,  so  that  an  instrument 
may  be  selected  which  is  as  large  as  the  urethra  will  admit. 

If  stricture  exist,  preliminary  dilation  may  be  practiced.  Eelatively 
large  tubes  may  then  be  used.  The  mistake  is  often  made  of  using  tubes 
that  are  too  long;  by  pressing  the  penis  down  about  the  tube  short  ones 
can  be  used  most  effectively. 

We  will  first  consider  that  form  of  chronic  urethritis,  the  chronicity  of 
which  depends  largel}^  upon  constitutional  conditions  or  a  general  predis- 


Fig.  44. — Author's  endoscopic  tubes. 


position  to  catarrh,  in  which  exploration  fails  to  detect  any  local  condition 
that  will  explain  the  discharge.  Cases  frequently  arise  in  which  all  forms 
of  special  treatment  fail  becattse  constitutional  peculiarities  are  disregarded. 
Debilitated,  cachectic,  and  strumous  subjects  require  tonics,  such  as  quinin, 
iron,  codliver-oil,  and  nux  vomica.  The  tincture  of  the  chlorid  of  iron  or 
the  mineral  acids  sometimes  act  well  by  improving  the  general  systemic  con- 
dition, toning  up  relaxed  and  flabby  mucous  membranes,  and  inhibiting 
excessive  secretion.  In  such  cases,  also,  benefit  may  result  from  the  in- 
ternal administration  of  vegetable  astringents,  ergot,  etc.     Turpentine  in 


TREATMENT    OF    CHRONIC    URETHRITIS.  155 

moderate  doses  is  sometimes  useful.  The  tincture  of  cantharides  may  also 
be  of  service. 

Local  treatment  is  often  unnecessary.  In  fact,  it  is  in  just  such  cases 
that  the  prolonged  use  of  injections  and  balsams  may  perpetuate  gleet. 
In  some  instances,  however,  in  conjunction  with  general  measures,  local 
applications  are  advantageous.  A  useful  application  is  fluid  extract  of 
hamamelis,  applied  by  a  cotton-wrapped  probe  via  the  endoscopic  tube  or 
urethral  speculum.  This  is  never  too  strong.  Patients  who  cannot  tolerate 
an  ordinary  injection  of  1  part  of  hamamelis  to  4  of  water  make  no  com- 
plaint Avhen  the  pure  fluid  extract  is  applied  in  this  manner.  It  is  some- 
times necessary  to  alternate  this  astringent  with  ointment  of  silver  nitrate, 
10  grains  to  the  ounce,  in  combination  with  stramomium  or  belladonna,  by 
means  of  the  cupped  sound.  Tannin  may  be  used  in  the  same  manner.  The 
patient  should  first  urinate;  a  full-sized  sound  should  then  be  passed  to 
empty  the  dilated  urethral  follicles,  after  which  the  medicated  application 
is  made.  Thin  ointments  may  be  used  via  a  specially-devised  syringe  or 
applicator. 

An  efficacious  plan  in  some  instances  is  the  prolonged  use  of  hot  water 


Fig.  45. — Clipped  sound  for  urethral  medication. 

in  combination  with  mineral  astringents,  the  patient  being  instructed  to 
inject  the  urethra  for  fifteen  or  twenty  minutes,  night  and  morning,  with 
water  as  hot  as  can  be  borne.  The  treatment  is  to  be  concluded  by  syring- 
ing the  canal  with  a  mild  solution  of  some  mineral  astringent  in  a  large 
quantity  of  hot  water.  This  is  to  be  injected  four  or  five  times  in  imme- 
diate succession  and  retained  for  some  time. 

It  may  be  considered  superfluous  to  advocate  a  change  of  climate  for 
patients^ with  this  form  of  chronic  urethritis,  yet,  when  the  general  con- 
dition seems  to  demand  it,  this  plan  may  be  advised,  and  will  often  be 
successful. 

The  rheumatic,  gouty,  syphilitic,  and  tubercular  diatheses  are  some- 
times responsible  for  chronic  urethritis.  The  same  remedies  are  required 
as  under  other  circumstances.  Combinations  of  colchicum,  mercury,  and 
iodid  of  potassium  are  likely  to  be  especially  serviceable  in  the  three  former 
conditions. 

Balsamic  preparations  may  be  continued  during  the  course  of  treat- 
ment for  chronic  urethritis,  providing  the  stomach  and  kidneys  tolerate 
them. 


156  URETHRITIS    AXD    GONORRHEA. 

Stricture  is  the  most  frequent  organic  condition  underlying  chronic 
urethritis.     Its  treatment  will  be  considered  in  its  proper  place. 

Congested  and  granular  patches  require  local  applications  via  the  endo- 
scope. It  should  be  remembered  that  powerful  general  applications  are 
apt  to  produce  injury.  It  is  unfortunate  that  the  surgeon  so  seldom  local- 
izes his  treatment^  but  continues  the  use  of  caustic  and  astringent  injec- 
tions-— shotgun  fashion — and  the  internal  administration  of  the  balsams  in 
a  futile  effort  to  relieve  something  that  a  single  well-directed  application 
might  perhaps  cure.  The  location  of  the  diseased  area  and  its  distance 
from  the  meatus  should  be  determined,  with  or  without  ocular  inspection. 
The  passage  of  a  steel  sound  upon  alternate  days  for  a  few  weeks  will  cure  a 
large  proportion  of  these  cases  by  crushing  the  minute  granulations,  empty- 
ing pus-distended  follicles,  producing  absorption  of  the  infiltrated  material, 
toning  up  the  mucous  membrane,  and  stimulating  repair.  When  this  has 
proved  ineffectual,  strong  applications  of  silver  nitrate  or  copper  sulphate 
should  be  made  directly  to  the  diseased  spot  through  the  endoscopic  tube. 
The  pure  crayon  of  copper  sulphate  or  silver  nitrate  is  safe  if  cautiously 


Fig.  4G. — Brown's  uretlnal  speculum. 

used.  The  silver  nitrate  may  be  fused  upon  the  end  of  a  l)lunt  probe  and 
touched  to  the  spot  very  lightly.  In  lieu  of  the  pure  caustic  strong  solu- 
tions of  copper  or  silver  may  be  used,  30  to  60  grains  to  the  ounce  being 
admissible.  Great  care  should  be  taken  le.st  an  excess  of  the  fluid  be  left. 
Wlien  the  diseased  area  is  within  three  inches  of  the  meatus  the  urethral 
sjseculum  is  often  serviceable  in  making  applications.  The  meatoscope  may 
also  be  useful.  It  is  in  chronic  urethritis  that  soluble  bougies  and  retro- 
jection  may  be  of  service. 

One  of  the  oldest  methods  of  treatment  of  gleet  is  the  injection  of 
astringents  of  gradually-increasing  strength.  Eicord's  old  formula  consists 
of  1  part  of  red  wine  to  3  of  water,  each  syringefnl  of  the  injection  being 
replaced  by  wine,  so  that  after  a  time  the  patient  is  using  the  pure  red  wine. 
Bumstead  speaks  highly  of  strong  solutions  of  the  persulphate  of  iron. 

Such  methods,  if  used  at  all,  must  be  secondary  to  measures  aimed  at 
the  removal  of  organic  conditions.  They  come  into  consideration  where  no 
organic  cause  for  gleet  can  be  found  or  after  such  causes  have  been  foimd 
and  removed,  the  gleet  still  persisting. 


TREATMENT  OF  CHEOXIC  UEETHKITIS.  157 

Many  cases  of  urethritis  are  perpetuated  by  a  contracted  meatus,  be- 
lli nd  which  urine  and  inflammatory  products  accumulate  and  produce  irri- 
tation. Meatotomy  is  advisable  in  chronic  urethritis  where  the  meatus  will 
not  admit  a  full-sized  sound. 

In  gleet  due  to  congested  and  granular  patches  a  slight  thickening  of 
the  involved  mucous  membrane  exists,  not  yet  sufficient,  perhaps,  to  be 
considered  a  stricture,  yet  often  requiring  the  same  treatment,  and  termi- 
nating in  a  constriction  of  the  lumen  of  the  canal.  The  patches  of  tough 
and  resilient  infiltration  are  usually  found  in  the  pendulous  portion  of  the 
urethra.  In  such  cases  the  discharge  is  sometimes  absolutely  resistant  to 
treatment  until  urethrotomy  is  performed  and  the  thin,  thickened  plaque 
divided.  When  this  plaque  involves  the  entire  urethral  circumference  it 
constitutes  stricture  of  large  caliber.  This  thickened  tissue  bears  the  same 
relation  to  the  gleet,  where,  because  of  circumscribed  limitation  of  the  proc- 
ess, there  is  no  noticeable  narrowing  of  the  canal,  as  Avhen  acknowledged 
stricture  exists. 

When  the  inflammatory  process  has  extended  to  the  deep  or  prostatic 


»fcm.WrfrlJJ.^U:«.li 


Fig.  47. — Author's  syringe  for  deep  injection. 

urethra,  deep  injections  are  necessary.  The  author  has  devised  a  syringe 
for  this  purpose  that  is  more  capacious  than  any  he  has  seen.  This  has  a 
num1)er  of  openings  for  the  ejection  of  fluid.  Silver  nitrate,  copper  sulphate, 
and  thallin  sulphate  are  the  best  remedies  in  these  cases.  Soluble  prostatic 
l)ougies  and  astringent  ointments  are  occasionally  of  great  service  in  poste- 
rior urethritis — i.e.,  follicular  prostatitis. 

Thallin  sulphate,  in  15-  to  20-per-Gent.  solution,  is  one  of  the  best 
antiseptic  and  astringent  applications  for  routine  use  in  the  posterior  ure- 
thra. The  thallin  may  be  alternated  with  irrigations  of  silver  nitrate  or 
potassium  permanganate  in  varying  strength.  In  some  cases  in  which 
there  is  chronic  inflammation  of  the  bulbous  urethra  benefit  may  result 
from  irrigation  with  hot  iodized  water  1  dram  to  the  pint.  In  some  obsti- 
nate cases  the  author  has  had  excellent  results  from  the  following  formula, 
introduced  through  the  endoscopic  tube: — 

IJ   lodoformi 3iv 

Tinct.  benzoini  co., 

Balsami   Peruv of  each  gj. — M. 


158  UEETHEITIS   AXD    GOXOREHEA. 

The  following  is  also  useful,  applied  in  the  same  manner: — 

5  lodinii  resub gr.  xx. 

Eucalyptol 3ij. 

Potassii  iodidi 3ij. 

Glycerin!  tannat Bss. 

Ac.  carbol gr.  xx. 

Bbroglyceridi    q.  s.  ad  Bij. — M. 

Mild  solutions  of  iodin  and  glycerin  are  often  of  great  value  in  the 
treatment  of  chronic  urethritis,  the  urethra  heing  painted,  via  the  endo- 
scope, with  solutions  of  from  3  to  10  grains  to  the  ounce.  Stronger  solu- 
tions may  be  carefully  used  in  selected  cases. 

By  far  the  most  reliable  treatment  for  chronic  urethritis,  on  the  aver- 
age, is  the  combination  of  dilation,  frequent  (daily  or  oftener)  irrigations 
via  a  short  urethral  nozzle.  The  most  useful  drugs  for  irrigation  are,  in 
order  of  superiority,  potassium  permanganate,  silver  nitrate,  mercury  bi- 
chlorid,  zinc  sulphate,  and  copper  sulphate.  Mercury  bichlorid  acts  espe- 
cially well  in  some  cases.  It  may  be  combined  with  potassium  perman- 
ganate. The  irrigations  should  be  copious — 2  quarts  of  fluid  being  usually 
advisable — and  as  hot  as  can  be  comfortably  tolerated.  The  treatment  de- 
manded by  special  local  conditions  should  be  combined  with  the  irrigations. 
The  strength  of  the  solutions  may  be  increased  gradually.  Potassium  per- 
manganate may  be  used  in  strength  varying  from  1-5000  to  1-3000  or  even 
1-1000,  silver  1-15,000  to  1-5000,  and  mercury  bichlorid  1-10,000  to  1-5000. 

Eecurrent  urethral  infection  is  not  only  often  due  to  chronic  follicular 
prostatic  infection  (posterior  urethritis),  but  prolonged  and  thorough  dis- 
infection of  the  prostatic  urethra  and  ducts  is  necessary  for  a  cure.  Fre- 
quent exacerbations  of  so-called  cystitis  and  recurrent  attacks  of  epididy- 
mitis may  occur  in  such  cases,  with  or  without  evident  urethral  inflam- 
mation. Xo  method  of  treatment  offers  the  slightest  hope  of  success  that 
does  not  involve  thorough  disinfection  of  the  nidus  of  the  disease:  i.e.,  the 
deep  urethra.  This  is  only  to  be  accomplished,  in  many  instances,  by  flush- 
ing daily  the  parts  Avith  copious  injections  of  silver  and  permanganate  solu- 
tions. The  most  satisfactory  way  to  accomplish  this  is  by  hydrostatic 
pressure.  The  author  presented  his  views  on  this  subject  some  years  ago 
in  the  Journal  of  Cutaneous  and  Genito-Urinar-y  Diseases,  under  the  cap- 
tion: "Irrigation  of  the  Deep  Urethra  and  Bladder  without  Tube  or  Cath- 
eter." The  same  journal  has  since  published  as  original  an  article  on  this 
method  by  another  gentleman.  The  coolness  of  the  appropriation  is  con- 
doned by  the  acceptance  of  the  method. 

The  author  uses  the  same  tube  for  posterior  and  anterior  urethral  irriga- 
tions. 

Oberlaender's  method  for  the  treatment  of  chronic  urethral  disease  is 
quite  popular  in  certain  quarters.  The  tripod  upon  which  its  claims  for 
eflficaey  rest  is  based  upon  sufficiently  familiar  principles,  viz.:    (1)  careful 


TKEATME^'T    OF    CHEOXIC    UKETHRITIS. 


159 


localization  of  the  conditions  that  jDerpetuate  the  inflammation,  via  endos- 
cop3^;  (2)  systematic  and  prolonged  dilation  of  the  urethra  by  specially- 
constrncted  dilators;  (3)  copious  antiseptic  irrigations.  Valentine  has  espe- 
cially commended  this  method.  So  far  as  the  author's  experience  has  gone 
the  method  is  often  very  effectual. 

Like  all  other  methods,  however,  that  of  Oherlaender  has 
its  limitations. 

All  measures  of  treatment  of 
chronic  urethritis  will  fail  if  the  pa- 
tient does  not  avoid  the  various  sexual, 
dietetic,  and  other  general  causes  of 
perpetuation  of  urethritis.  The  aver- 
age patient  with  chronic  urethral  dis- 
ease lays  the  responsibility  of  cure 
entirely  upon  the  surgeon,  and  ex- 
pects it  to  he  accomplished  without 
the  slightest  co-operation  on  his  own 
part.  The  capacity  for  deceit  of  the 
average  patient  with  urethral  disease 
is  something  marvelous.  It  is  cer- 
tainly discouraging  to  have  a  patient 
present  himself  with  acute  or  sub- 
acute urethritis  a  few  weeks  after  dis- 
missal apparently  cured  of  stricture 
and  gleet,  and  solemnly  vow  that  he 
has  not  played  the  hon  vivant  or  roue 
during  that  time.  It  is  possible  that 
a  few  such  patients  do  not  lie,  but  it 
is  difficult  to  believe  that,  in  the  ab- 
sence of  an  exciting  cause,  a  canal  that 
has  been  thoroughly  dilated  and  the 
secretion  of  which  has  been  entirely 
checked  can  spontaneously  lapse  into 
an  acute  inflammatory  state  long  after 
apparent  cure  so  frequently  as  pa- 
tients would  have  us  helieve. 

Possibly  genito-urinary  patients 
are  quite  as  reliable  as  others,  but  such 
is  not  the  impression  usually  made 
upon  the  surgeon's  mind.  The  aver- 
age individual  should  have  sufficient 


48. — Oberlaender's  dilator   (straight).     Fio-. 
dilator  with  deep  curve. 


49.- 


Fig.  49. 
-Oberlaender's 


160  UEETHEITIS    AND    GOXOERHEA. 

respect  for  his  own  physical  interests  to  he  frank  and  honest  with  his  phy- 
sician. It  has  been  aptly  said  that  "the  man  avIio  deceives  his  doctor  is  a 
fool."  If  this  be  true,  however,  the  intelligence  of  a  large  proportion  of 
jDatients  is  open  to  impeachment.  Whether  the  moral  turpitude  of  the  aver- 
age venereal  i^atient  is  due  to  shame  or  a  desire  to  lessen  his  financial  re- 
sponsibility to  his  surgeon  is  a  question  difficult  to  answer.  To  say  the 
least,  very  few  patients  are  so  hard  to  manage  as  a  certain  proportion  of 
those  met  with  in  genito-urinary  practice. 

Special  Teeatjient  of  the  Complicatioiv's  of  Urethritis. — Severe 
Chordee  and  Uretliral  Hemorrhage. — This  is  best  controlled  by  the  anaphro- 
disiac  remedies  already  recommended  and  the  application  of  the  cold-water 
coil,  or  a  balloon-rubber  ice-bag.  The  danger  of  hemorrhage  is  usually 
obviated  by  proper  management  of  chordee.  When  severe  bleeding  does 
occur  from  rupture  of  the  corpus  spongiosum  by  forcible  straightening  of 
the  penis,  it  may  be  controlled  in  most  instances  by  the  cold  coil.  If  this 
is  unsuccessful,  a  gum  catheter  may  be  passed  into  the  urethra  beyond  the 
])oint  of  rupture,  and  the  cold-water  coil  wrapped  tightly  around  the  penis, 
or,  better,  a  firm  bandage  may  be  applied  without  the  catheter.  The  oil  of 
turjDentine  internally  is  often  of  great  service  in  urethral  hemorrhage. 

Folliculiiis  and  Periurethral  Fhleginoii.  —  These  conditions  are  best 
treated  on  conservative  principles  in  most  cases.  So  soon  as  either  con- 
dition develops,  injections  should  be  stopped  and,  if  possible,  the  patient  kept 
perfectly  quiet.  Hot  applications  will  often  secure  resolution.  Some  cases 
are  very  stubborn,  but,  as  a  rule,  the  little  tumors  characteristic  of  follicu- 
litis become  absorbed;  sometimes,  however,  they  remain  as  small,  circum- 
scribed indurations  that  keep  up  irritation.  The}^  often  determine  the 
localization  of  stricture.  Under  such  circumstances  they  may  be  excised. 
Excision  has  been  recommended  as  a  routine  practice,  under  the  supposi- 
tion that  the  tumors  inevitably  suppurate,  and  that  there  is  great  danger  of 
rupture  into  the  urethra  followed  by  extravasation  of  urine,  etc.  As  a  rule, 
however,  as  the  inflammation  of  the  urethra  subsides  the  duct  of  the  follicle 
opens  and  the  little  sac  discharges  into  the  urethra,  the  wall  of  the  follicle 
eventually  shrinking  doAvn  to  its  normal  size.  The  emptying  of  the  follicle 
is  usually  evidenced  hj  sudden  increase  of  urethral  discharge.  The  follicles 
may  successively  refill  and  discharge  indefinitely,  causing  corresponding  re- 
infections of  the  urethra.  Should  swelling  be  marked  or  painful,  or  if 
fluctuation  be  evident  in  periurethral  phlegmon,  immediate  incision  is  best. 
Conservatism  is  usually  wise,  but  it  ma}-  be  carried  too  far.  It  is,  however, 
presumed  that  the  surgeon  will  know  when  to  operate.  In  doubtful  cases 
there  may  be  more  danger  in  delay  than  in  early  incision. 

Conservatism  is  not  so  safe  in  periurethral  phlegmon  of  the  perineal 
urethra  as  when  the  i^endulous  portion  is  involved.  AVhen  the  perineum 
becomes  hard  and  brawny  an  early  incision  should  be  made,  the  operation 
itself  being  harmless.     If  al)scess  has  formed  and  opened  into  the  urethra 


TEEATMENT    OF    THE    COMPLICATIONS    OF    URETHEITIS.  161 

before  the  patient  comes  under  observation,  free  incisions  should  be  made 
at  once.  If  at  any  time  marked  increase  in  the  perineal  swelling,  chills, 
hectic,  and  general  constitutional  disturbance  should  occur  as  evidences  of 
new  purulent  foci  or  urinary  infiltration,  or  if  the  perineal  swelling  is  ex- 
tensive, Avith  a  disposition  to  pointing  of  pus,  external  perineal  section  is 
required.  A  fistula  results  that  usually  heals. spontaneously.  Sometimes, 
however,  it  requires  surgical  attention  later  on. 

Betention  of  Urine. — The  conditions  producing  retention  in  urethritis 
are  to  be  carefully  analyzed  in  selecting  its  treatment.  The  factors  in  its 
production  are:  (1)  inflammatory  swelling  of  the  mucous  membrane,  with 
consequent  diminution  of  the  urethra;  (2)  irritation  produced  by  the  acid 
urine;  (3)  prostatic  congestion;  (4)  muscular  spasm.  In  patients  who  have 
suffered  from  previous  urethritis  there  may  be  stricture,  to  which  the  fore- 
going factors  are  superadded  as  plus  conditions.  A  prostatic  abscess  may 
exist,  causing  retention  by  simple  pressure. 

The  indications  for  treatment  are  plain:  sedatives,  derivatives,  anti- 
spasmodics, alkaline  diluents,  and  rest  comprising  the  main  features. 

A  full  dose  of  morphin  hypodermically  or  per  rectum  and  a  hot  sitz- 
bath  repeated  as  occasion  demands  are  useful.  Ice  in  the  rectum  assists  in 
relieving  local  congestion.  Leeches  to  the  perineum  and  anus  are  often  very 
valuable.  Hot  demulcent  infusions  internally  are  of  service.  If  prostatic 
abscess  exists,  incision  is  necessar)^ 

An  injection  of  cocainized  oil  may  be  serviceable.  The  dread  of  pain- 
ful micturition,  and  the  reflex  effect  of  irritating  urine,  are  important  in  the 
production  of  retention;  cocain  may  relieve  this.  The  catheter  is  a  last 
resort.  It  is  often  far  better  to  tap  above  the  pubes  than  to  use  the  catheter. 
If  for  any  reason  it  is  decided  to  catheterize,  a  general  anesthetic  may  be 
required,  although  cocain  is  usually  sufficient.  Great  gentleness  is  demanded 
in  the  passage  of  instruments.  The  urethra  should  first  be  thoroughly  and 
deeply  flushed  with  a  mild,  warm  antiseptic  solution.  We  may  thus  avoid 
infecting  the  deep  urethra  and  bladder.  In  the  author's  experience  instru- 
mental interference  has  rarely  been  necessary. 

Cowperitis. — Cowperitis  requires  rest,  leeches  to  the  perineum,  and  con- 
tinuous hot  applications.  If  the  perineum  becomes  tense  and  brawny,  or 
severe  pain  or  retention  of  urine  develops,  an  incision  should  be  made  with- 
out waiting  for  pus-formation.  If  improvement  does  not  occur  within  a 
Aveek  or  ten  days,  incision  is  warranted  in  any  case.  In  many  instances  the 
process  resolves  without  pus-formation,  especially  if  the  perineal  cellular 
tissue  is  not  extensively  involved.  Cowperitis  is  not  always  the  result  of 
gonorrhea.  The  author  has  seen  a  typic  case  in  a  tuberculous  patient  who 
had  no  urethral  disease. 

When  allowed  to  discharge  spontaneously,  the  pus  in  Cowperitis  usu- 
ally appears  externally.  It  may,  however,  open  into  the  urethra,  resulting 
in  fistula,  or  infiltration  of  urine,  abscess,  and  sloughing. 


162  UEETHEITIS    AXD    GOXORRHEA. 

The  treatment  of  j^rostatitis,  e3'Stitis,  epididymitis,  orchitis,  and  sem- 
inal vesiculitis  occurring  as  complications  of  gonorrhea  will  be  considered  in 
the  chapters  to  which  each  properly  belongs. 

Gonorrheal  Bheumatism. — The  treatment  of  this  complication  is  not 
satisfactor}^,  being  usually  palliative  rather  than  curative.  The  treatment 
for  urethritis  should  usually  be  continued;  the  sooner  the  local  condition 
improves,  the  sooner  the  rheumatism  will  yield.  If,  however,  the  discharge 
has  ceased,  it  is  best  to  let  the  urethra  severely  alone.  Urinary  antiseptics 
are  always  indicated.  Debilitated  patients  require  tonics,  such  as  strych- 
nin, arsenic,  iron,  and  codliver-oil.  The  skin  and  bowels  should  be  kept 
active  and  elimination  favored  by  the  hypodermic  use  of  pilocarpin.  Pain 
may  demand  opiates,  hot  applications,  and  fixation  of  the  inflamed  joint. 
Should  the  knee  be  severely  involved.  Buck's  extension  apparatus  should  be 
applied.  The  application  of  fifteen  or  twenty  leeches  to  the  joint  Avill  often 
prove  serviceable.  Flannels  wrung  out  of  hot  water  and  sprinkled  with  tur- 
pentine are  useful.  As  the  inflammation  subsides,  blisters  or  iodin  Avill  be 
found  to  promote  resolution.  Mercury  and  potassium  iodid  internally  are 
of  great  service  in  the  chronic  stages.  The  author  has  had  excellent  results 
from  intra-articular  injections  of  iodoform  emulsion.  It  is  well  to  try  the 
salicylates;  the  rheumatic  or  gouty  diathesis  may  be  a  predisposing  cause. 
The  larger  joints,  such  as  the  knee,  demand  the  plaster  bandage  so  soon 
as  the  acute  inflammation  has  subsided.  Passive  movement  and  perhaps 
measures  to  break  up  ankylosis  are  required  later.  Turkish  baths,  static 
electricity,  friction,  and  massage  are  serviceable  adjuvants.  Static  elec- 
tricity is  particularly  beneficial.  This  remedy  is  of  great  value  in  obstinate 
cases  of  chronic  enlargement  of  joints.  During  the  acute  stage  of  gonor- 
rheal rheumatism  a  milk  diet  is  very  essential. 

Gonorrlieal  liibo,  halanitis,  and  vegetations  have  received  attention  in 
other  chapters  of  this  work. 


CHAPTEE  X. 

GOXORKHEA    IX    THE    FeMALE. 

Gonorrhea  in  the  female  as  now  understood  is  more  often  met  with  in 
the  special  field  of  gynecology  than  in  that  of  venereal  diseases.  This  would 
seem,  a  priori,  a  trifle  paradoxic,  j^et  if  the  more  advanced  views  he  cor- 
rect, the  correlatives  of  gonorrhea  and  gleet  in  the  male  are  too  frequently 
regarded  as  simple  and  non-venereal  in  the  female.  Then,  too,  the  more 
serious  results  of  gonorrhea  in  women  are  at  the  ^^resent  time  relegated  to 
ahdominal  surgery:  a  field  that  the  gynecologic  specialist  would  fain  mo- 
nopolize. A  knowledge  of  these  conditions  in  their  various  phases,  and  a 
just  appreciation  of  their  relation  to  venereal  infection,  are  nevertheless 
absolutely  indispensable  to  the  genito-urinary  surgeon. 

The  special  consideration  of  the  effects  of  gonorrheal  infection  upon 
the  female  sexual  organs  is  of  great  practical  value,  the  more  especially  as 
the  materies  morM  of  the  disease  is  primaril}^  generated  in  Avomen.  It  is  a 
striking  clinical  fact  that  gonorrheal  inflammation  in  the  female  rarely 
presents  conditions  physically  analogous  to  those  observed  in  the  male. 
Vaginitis  of  venereal  origin  is  exceptional,  and  urethritis,  the  only  real  an- 
alogue, is  excessively  rare  in  women,  and,  moreover,  does  not  always  occur 
Mdien  virulent  vaginitis  exists.  The  rarity  of  virulent  vaginitis,  even  in 
that  numerous  class  of  unfortunates  from  whom  the  male  acquires  the  dis- 
ease, is  only  explicable  by:  1.  The  existence  of  latent  gonorrheal  processes 
of  a  greater  or  less  degree  of  virulency  in  the  female.  2.  The  gradual  ac- 
climation of  the  vaginal  mucous  membrane  to  the  toxic  products  of  organic 
decomposition  slowly  formed  in  the  female  generative  apparatus.  If  it  be 
accepted  that  the  urethra  of  the  male  may  become  acclimated  to  morbid 
conditions  existing  in  the  female,  as  is  often  seen  in  the  husbands  of  women 
who  are  infectious  to  any  strange  male  with  whom  they  may  sustain  sexual 
relations,  it  must  also  be  accepted  that  the  vagina  becomes  inured  to  the 
contact  of  the  irritating  products  of  morbid  conditions  of  the  mucous  mem- 
brane higher  up:  i.e ,  becomes  tolerant  of  autogenetic  poisons.  This  same 
tolerance  explains  the  resistance  of  such  Avomen  to  the  disease  when  they 
are  exposed  to  contagion.  3.  The  relatively-inherent  toughness  of  the 
vagina,  as  a  consequence  of  which  it  may  serve  as  a  vessel  in  which  toxic 
materials  can  be  elaborated  without  itself  becoming  infected  by  them. 
This  inherent  resistancy  does  not  extend  to  the  endometrium — cervical  or 
corporeal — Fallopian  tubes,  and  peritoneum:  hence  women  may  be  affected 
by  more  or  less  active  gonorrheal  processes  in  these  parts  while  the  vagina 
is  apparently  healthy. 

The  importance  of  a  knowledge  of  tlie  direct  and  remote  results  of 
gonorrhea  in  women  can  hardly  be  overestimated,  and  has  only  recently 

'(163) 


164  GOXORKHEA    IX    THE    FEMALE. 

received  its  just  share  of  attention.  Foreshadowed  by  the  labors  and  once 
ridiculed  theories  of  the  great  pioneer  in  this  field,  Noeggerath,  the  re- 
searches of  modern  operative  gynecologists  are  developing  most  astonishing 
facts.  The  more  carefully  we  study  pelvic  diseases  in  women,  the  narrower 
their  etiologic  field  becomes,  and  the  more  frequently  they  are  found  to  be 
dependent  upon  gonorrhea.  Thus,  Avhen  freed  from  pathologic  and  anatomic 
errors,  pelvic  inflammations  are  found  to  be  dependent,  in  the  majority  of 
cases,  if  not  all,  upon  tubal  disease,  and  tubal  disease  is  unquestionably 
almost  always  due  to  gonorrhea  and  its  congeners  or  derivatives. 

It  must  be  remembered  in  this  connection  that  there  are  two  ways  in 
which  gonorrheal  infection  may  produce  morbid  conditions  in  women. 
This,  unfortunately,  seems  to  have  been  overlooked  by  Noeggerath  and  his 
disciples,  Avho  apparently  hold  that  the  results  of  gonorrhea  manifested  by 
infectious  inflammations  and  suppurations  of  the  uterus,  Fallopian  tubes, 
parametrium,  and  ovaries  are  the  result  of  primary  infection  from  im- 
cleanly  intercourse.  This  is  a  one-sided  view  of  the  question,  for,  as  a  con- 
sequence of  various  exciting  causes,  the  pelvic  organs  of  the  female  may  be- 
come infected  by  certain  inflammatory  and  putrefactive  processes  in  her  own 
generative  apparatus,  not  necessarily  dependent  upon  antecedent  hetero- 
genetic  infection:  i.e.,  sexual  contagion.  While  willing  to  accept,  in  the 
main,  the  doctrines  of  the  Noeggerath  school,  the  author  is  strenuously 
opposed  to  the  view  that  infection  from  without  is  tlie  fons  origo  et  mali 
in  all  cases. 

Xoeggerath's  theory  as  originally  formulated  implies: — 

1.  That  nearly  all  individuals  who  have  at  a  more  or  less  remote  period 
contracted  gonorrhea  and  have  apparently  been  cured  are  capable  of  im- 
parting infection  to  the  female.  Thus,  most  men  who  have  ever  had  the 
disease,  according  to  Noeggerath,  sooner  or  later  infect  their  wives. 

2.  That  this  infectiousness  on  the  part  of  the  male  is  in  many  in- 
stances latent,  but  may  possibly  become  perceptible  by  the  occurrence  of 
urethritis  of  greater  or  less  degree  of  severity,  as  a  consequence  of  sexual 
intercourse. 

3.  That  consequent  upon  this  latent  condition  of  gonorrhea  in  the 
male  there  occurs  a  similar  latent  infection  of  the  wives  of  those  thus 
affected. 

4.  That  the  majority  of  women  who  marry  men  who  have  at  one  time , 
or  another  had  gonorrhea  become  sooner  or  later  the  subjects  of  uterine  i 
and  pelvic  inflammations. 

These  views  are  certainly  striking  and  suggestive,   especially  if  the 
large  proportion  of  women — particularly  in  large  cities — who  have  pelvic 
troubles  of  various  kinds  be  given  due  consideration.    It  is  certainly  peculiar  i 
that  so  natural  a  state  as  matrimony  should  afflict  women  with  so  manyj 
varied,  severe,  and  annoying  disorders  of  the  sexual  organs.     Faulty  hy- 
giene, improper  habits  and  modes  of  living,  and  hereditary  transmission  of 


xoeggebath's  THEOKY.  165 

physical  defects,  associated  Avitli  sexual  excess,  explain  these  troubles  to  a 
certain  extent;  add  to  these  etioloo-ic  factors  deliberate  and  vicious  inter- 
ference with  Xature's  processes  by  the  performance  of  abortion,  and  we 
have  a  series  of  all-sufficient  causes  for  diseases  of  the  female  sexual  organs. 
It  must  be  remembered,  however,  that  the  disproportion  in  frequency  of 
such  diseases  in  city-bred  as  compared  with  country  women,  is  greater  than 
can  be  reasonably  explained  by  these  various  factors.  Add  the  elements  of 
latent  or  active  infection  in  many  husbands,  prostitution,  and  illicit  inter- 
course,— the  opportunities  for  which  are  greater  in  cities,^ — with  their  at- 
tendant facilities  for  the  generation  and  transmission  of  infection,  and  the 
explanatory  chain  is  complete. 

With  regard  to  the  frequency  of  gonorrhea  among  the  inhabitants  of 
cities,  Noeggerath  said  some  years  ago:  "I  do  not  know  what  the  state  of 
matters  in  other  cities  is;  I  did  not  know  how  we  stood  in  New  York  until 
I  questioned  the  husband  of  every  woman  who  came  under  treatment;  but 
I  believe  we  may  apply  here  the  dictum,  of  Eicord,  that  800  men  in  1000 
have  had  gonorrhea."  He  goes  further  and  says:  "I  believe  that  I  do  not 
exaggerate  when  I  say  that  gonorrhea  in  90  per  cent,  of  cases  remains 
uncured.  Of  every  hundred  women  who  have  married  men  formerly  af- 
fected by  gonorrhea,  hardly  ten  remain  well,  the  others  are  afflicted  by 
some  of  the  ailments  which  I  have  attempted  to  describe."^ 

Making  -due  allowance  for  statistic  errors  and  exaggerations  in  the 
original  assertions  of  Xoeggerath,  it  must  still  be  admitted  that  gonorrheal 
infection  may  cause  any  or  all  of  a  series  of  disastrous  results  in  the  female 
pelvic  organs.  Thus,  metritis,  endometritis,  salpingitis,  hydrosalpinx,  pyo- 
salpinx,  ovaritis,  parametritis,  pelvic  peritonitis,  menstrual  disorders,  and 
sterility  may  occur,  according  to  the  age  and  severity  of  the  process  and 
the  character  of  the  structures  affected.  Although  rare,  vesical,  urethral, 
and  even  renal  disease  of  inflammatory  type  may  occur,  as  in  the  male. 

As  already  suggested,  these  results  may  occur  from  infection  of  the 
affected  structures  without  the  contagion  being  necessarily  heterogenetic. 
The  primary  point  of  departure  is  certainly  not  the  male  urethra,  but,  so 
far  as  clinical  evidence  and  theoretic  reasoning  seem  to  show,  must  neces- 
sarily be  the  generative  apparatus  of  the  female. 

Admitting  the  truth  of  the  foregoing  remarks,  it  must  be  conceded 
that  a  woman,  whose  generative  tract  is  in  a  condition  capable  of  infecting 
any  male  with  Avhom  she  may  have  intercourse,  is  also  capable,  under  favor- 
able conditions,  of  infecting  any  portion  of  her  own  generative  tract  that 
happens  to  be  susceptible  to  the  irritating  effects  of  the  autogenetic  poison. 
Such  infection  may  occur  without  any  exciting  cause,  although  in  perhaps 
the  majority  of  instances  some  special  circimistance  or  other  is  necessary 
to  the  development  of  infectious  inflammation.     Let  it  be  supposed,  for 


"Morbid  Results  of  Latent  Gonorrhea  in  the  Female,"  1872. 


166  GOXOEEHEA    IN    THE    FEMALE. 

example,  that  a  woman  of  uncleanly  habits,  easy  virtue,  and  debilitated 
constitution  suffers  from  abortion,  as  a  consequence  of  which  her  par- 
turient canal  is  in  a  condition  of  traumatism;  the  same  poison — which 
various  circumstances  of  environment  have  caused  to  develop  in  her  gen- 
erative apparatus — that  would  develop  urethritis  in  the  male  may  obviously 
produce  in  her  such  inflammatory  conditions  as  severe  metritis,  endome- 
tritis, salpingitis,  cellulitis,  pelvic  peritonitis,  etc.,  etc.  It  is  admitted  that 
the  male  may  contract  urethritis  from  women  who,  so  far  as  can  be  de- 
termined,— macroscopically  or  microscopically, — have  no  specific  inflamma- 
tion of  the  generative  tract,  but  are  uncleanly  and  perhaps  afflicted  with 
apparently  ordinary  catarrhal  conditions  of  the  mucous  membrane,  gen- 
erating an  acrid  discharge.  It  seems  reasonable  to  suppose  that,  when  the 
sexual  organs  of  such  women  become  wounded  in  the  process  of  parturition, 
they  become,  at  once,  susceptible  to  the  local  eff'ects  of  this  same  auto- 
genetic  poison.  The  author  ventures  to  assert  that,  leaving  out  of  consid- 
eration pelvic  inflammation  due  to  septic  infection  at  the  hands  of  the 
accoucheur,  the  majority  of  cases  of  pelvic  disease  following  labor,  premature 
or  normal,  are  due  to  autoinfection.  There  may  be  absolutely  no  lines  of 
differentiation  to  be  drawn  between  cases  in  which  the  infection  is  devel- 
oped de  novo  in  the  woman  and  those  in  which  it  has  been  imparted  to  her 
through  uncleanly  intercourse.     The  results  are  the  same. 

It  is  unquestionably  true  that  many  cases  of  urethritis  in  the  male  re- 
main infectious  for  some  time — perhaps  man}^  months — after  a  gonorrhea 
is  apparently  cured;  yet  it  is  probable  that  uncomplicated  cases  in  which 
the  disease  has  apparently  been  cured  for  six  months  or  more  are,  in  the 
absence  of  stricture,  generally  non-contagious.  There  are  even  instances  in 
which,  although  slight  stickiness  of  the  meatus  still  remains,  there  are  no 
properties  of  contagion,  and  it  is  perfectly  safe  to  sanction  marriage.  Ex- 
treme caution  and  careful  tests  are,  of  course,  necessary  in  this  respect. 
That  patients  with  stricture  should  not  be  allowed  to  marry  without  careful 
preliminary  treatment  goes  without  saying.  The  author  has  no  disposition 
to  antagonize,  in  any  sense,  the  views  of  the  Noeggerath  school,  but  never- 
theless desires  to  protest  against  the  illiberality  of  ascribing  the  results  of 
gonorrheal  infection  to  direct  contagion  in  all  cases,  with  complete  disre- 
gard of  the  numerous  morbid  possibilities  of  autoinfection. 

It  will  be  noted  that  in  the  foregoing  remarks  the  author  has  used 
the  qualification  "uncomplicated  cases"  in  discussing  the  probable  duration 
of  infection.  Allusion  has  also  been  made  to  tests  of  infectiousness.  These 
points  demand  further  expatiation. 

Cases  of  gonorrhea  in  the  male,  complicated  by  infection  of  the  various 
glandular  structures  tributary  to  the  urethra,  are  characterized  by  indef- 
initely-prolonged infectiousness.  Thus,  folliculitis,  Cow]3eritis,  and  espe- 
cially prostatitis, — i.e.,  posterior  urethritis, — and  involvement  of  the  rasa 
deferentia  and  testes  are  apt  to  render  the  unluckv  subject  infectious  for 


LATENT   GONOKRHEAL    INFECTIOX.  167 

many  months, — several  years  in  some  instances.  When  abscess  or  fistula 
occurs  as  a  complication  of  urethritis,  there  is  constant  danger,  not  only 
of  autoinfection  of  the  male,  but  of  infection  of  the  female  in  case  of  ex- 
posure. 

It  is  probable  that  no  test  is  infallible,  but,  after  giving  the  time-limit 
due  consideration,  and  removing  so  far  as  possible  any  local  lesion  that  may 
exist,  free  indulgence  in  beer-drinking  and  the  injection  of  nitrate  of  silver 
in  a  strength  of  5  to  10  grains  to  the  oimce  is  likely  to  develop  latent  in- 
fection in  the  male.  The  resulting  secretion  should  be  examined  micro- 
scopically, and,  if  germs  resembling  gonococci  are  found,  culture  and 
inoculation  experiments  should  be  made.  An  opinion  that  is  even  approxi- 
mately authoritive  cannot  otherwise  be  given.  The  surgeon  is  likely  to  err 
upon  either  side  of  the  question.  The  author  has  elsewhere  alluded  to  a 
case  in  which  repeated  examinations  of  the  semen,  extending  over  a  period 
of  several  years,  showed  the  presence  of  germs  that  were  pronounced  gono- 
cocci. Eventually,  however,  these  germs  proved  innocuous  by  culture  and 
inoculation  tests;  they  were  probably  infectious  originally,  but  the  remorse- 
less law  of  evolution  had  finally  overcome  their  morbific  propensities. 

To  make  the  test  complete,  examinations  of  the  seminal  fluid  should 
always  be  made,  sexual  congress  and  the  use  of  the  ordinary  condom  being 
the  only  practicable  method  of  collecting  the  fluid  for  examinations.  This 
involves  fornication,  as  a  rule,  but,  as  the  method  is  usually  perfectly  con- 
sistent with  the  patient^s  ordinary  habits  of  life,  there  are  no  particular 
moral  or  esthetic  objections  to  be  urged. 

Typic  gonorrheal  vaginitis  is  usually  seen  in  comparatively  cleanly 
and  healthy  women  who  have  become  infected  with  the  products  of  in- 
dubitably specific  urethritis  in  the  male.  The  younger  and  more  cleanly 
the  patient,  the  more  virulent  the  vaginitis.  It  is  noteworthy  that  specific 
vaginitis  in  young  children  is  usually  very  severe.  The  author  has  met  with 
but  three  instances  of  typic  virulent  vaginitis  from  contagion  occurring  in 
young  female  children:  one  in  a  child  of  ten  years,  another  of  four,  and 
a  third  of  ten  years,  ail  of  which  were  traced  to  their  source.  Earely,  in- 
deed, is  such  severe  specific  infiammation  seen  in  the  adult  female  as  in 
children. 

In  connection  with  the  possible  infectiousness  of  chronic  urethral  dis- 
ease in  the  male,  attention  is  again  directed  to  the  possibility  of  transforma- 
tion of  the  virulent  process  in  such  wise  that,  although  no  longer  capable 
of  causing  virulent  infiammation,  there  are  formed  at  the  site  of  the  ure- 
thral disease  non-specific  germs  and  toxins  capable  of  exciting  gynecic  dis- 
ease of  various  kinds. 

The  possibility  of  gonorrheal  processes'  becoming  latent  in  the  female 
i>  of  great  importance  Avith  reference  to  the  transmission  of  the  disease  to 
the  male.  For  example,  in  the  event  that  a  woman  has  been  affected  at 
one  time  or  another  with  a  ffonorrhea  that  has  become  localized  in  the 


168  GOXOREHEA  IN  THE  FEMALE. 

Fallopian  tubes,  it  is  probable  that  under  sexual  excitement  or  during  men- 
struation a  small  quantit}^  of  the  retained  germ-laden  secretion  may  be  ex- 
truded into  the  uterus,  mingling  with  the  secretions  of  that  organ  and  the 
vagina,  eventually  coming  in  contact  with  the  urethra  of  the  male,  and 
exciting  therein  specific  or  simple  urethritis,  the  type  depending  on  whether 
the  typic  gonococcus  is  still  present  or  not.  The  woman's  own  mucous 
membranes  are  relatively  imminie  to  infection  because  their  susceptibility 
has  been  exhausted  by  the  primary  infection.  Upon  examination  such 
women  present  no  traces  of  virulent  disease,  although  they  are  usually  found 
to  have  more  or  less  uterine  difficulty. 

Parallel  cases  may  occur  in  which  the  primary  source  of  the  disease  is 
not  infection  from  without.  Supposing,  for  example,  as  a  consequence  of 
germ-evolution  favored  by  sexual  excess,  filth,  simple  uterine  inflammation, 
intemperance,  cachexia,  and  so  on,  a  woman  develops  gonorrheal  infection 
de  novo;  her  own  mucous  membranes  becoming  graduall)^  involved,  the 
process  finally  disaj)pears  elsewhere,  but  localizes  itself  in  the  Fallopian 
tubes  and  endometrium;  as  a  consequence  of  some  of  the  exciting  causes 
heretofore  mentioned,  the  pent-up  poison  is  discharged  into  the  vagina, 
and  causes  urethritis  in  the  first  unlucky  male  who  has  intercourse  with 
her.  Upon  examination — even  upon  microscopic  examination  of  her  se- 
cretions— she,  too,  presents  no  evidences  of  disease  other  than  ordinary 
endometritis,  and  perhaps  even  this  in  mild  degree. 

To  go  a  little  further  with  the  morbid  possibilities  of  latent  gonorrheal 
processes  in  the  Fallopian  tubes,  let  it  be  supposed  that,  as  .a  consequence 
of  sexual  excitement,  traumatism,  parturition,  or  violent  exertion,  a  small 
quantity  of  the  infectious  secretion  is  discharged  into  the  peritoneal  cavity; 
obviously,  localized  peritonitis  with  possible  pelvic  abscess  is  likely  to  re- 
sult. It  is  a  suggestive  fact  that  latent  gonorrheal  processes  do  not  usu- 
ally produce  general  peritonitis,  probably  because  of  some  transformation 
of  the  mater ies  morhi.  This  disease  may  occur  as  a  consequence  of  gonor- 
rhea, but  almost  invariably  as  a  direct  result  of  rupture  of  a  pelvic  abscess — 
which  is,  in  itself,  due  to  gonorrheal  infection — or  extension  of  virulent 
vaginitis,  endometritis,  and  salpingitis.  The  jDeritoneum,  like  the  bladder, 
is  relatively  immune  to  the  gonococcus,  but  susceptible  to  the  mixed  in- 
fection of  secondary  gonorrheal  processes,  especially  if  the  products  of  such 
mixed  infection  be  discharged  suddenly  and  in  large  quantity  into  the 
peritoneal  cavity.  Localization  by  plastic  hanph-barriers  usuall}^  protects 
the  general  peritoneum  Avhere  the  infection  is  gradual  and  the  amount  of 
infectious  material  limited. 

Chronic  gonorrheal  inflammation  may  become  localized  in  the  glandulce 
Nahothii  and  Bartholini;  under  such  circumstances  women  may  continue 
to  transmit  contagion  for  an  indefinite  period  after  all  clinical  and  micro- 
scopic evidences  of  specific  vaginitis  or  endometritis  have  disappeared. 
This  explains  many  of  those  puzzling  cases  in  which  urethritis  is  contracted 


UKETHRITIS    IN    WOMEN.  169 

from  apparently  healtlw  women.  Sucll  women  continue  to  be  infections 
in  some  instances,  until  the  glandular  foci  of  infection  have  been  extirpated 
by  the  knife. 

The  urethra  of  the  female  is  very  rarely  involved  in  virulent  inflam- 
mation, on  account  of  its  protected  situation.  The  vulva,  at  least  the  more 
external  portions  of  it,  not  being  particularly  susceptible  to  virulent  in- 
fection, the  process  does  not  readily  extend  to  the  meatus;  possibly  it  never 
does  so,  excepting  in  cases  of  typic  virulent  vaginitis  due  to  specific  in- 
fection. Whenever  urethritis  develops  in  the  course  of  vaginitis,  with  or 
without  vesical  inflammation,  it  is  prima  facie  evidence  that  the  disease  was 
primarily  caused  by  infection.    This  fact  is  not  due  to  any  peculiar  selective 


Fig.   50. — Gonorrheal  inflammation  of  the  left  vulvo-vaginal  gland. 
(After  Bumstead.) 

property  of  the  gonococcus,  but  to  the  fact  that  the  urethra  is  very  rarely 
affected  excepting  in  the  more  violent  cases  of  vaginal  inflammation,  which 
are  invariably  due  in  the  female  to  venereal  contagion.  It  should  be  noted, 
however,  that,  while  urethral  inflammation  is  fair  presumptive  evideiice  of 
specific  infection,  its  absence  proves  nothing.  Most  cases  of  gonorrheal  in- 
fection in  women  are  not  only  uncomplicated  by  urethritis,  but  exception- 
ally by  vaginitis. 

It  has  been  claimed  by  Martineau  that  the  reaction  of  the  secretion  of 
vaginitis  determines  the  diagnosis  of  its  specific  or  non-specific  character. 
He  claims  that  the  pus  of  specific  vaginitis  is  always  acid,  while  in  the 
simple  variety  it  is  alkaline.    It  is  to  be  hoped  that  this  fallacious  test  may 


170  .   GOXOKEHEA    IX    THE    FEMALE. 

not  be  depended  upon  in  differential  diagnosis.  No  one  has  thus  far  con- 
firmed the  opinion  of  Martineau.  The  only  test,  as  in  the  case  of  the  male, 
is  microscopic  and  culture  study  of  the  secretions,  and  even  this  is  open  to 
serious  fallacies — more  serious  than  in  the  male. 

Symptoms  and  Couese  of  Gonorrhea  in  the  Female. — The  multi- 
form results  of  gonorrheal  infection  in  women  present  a  wide  range  of 
varying  conditions  which,  save  from  the  stand-point  of  infectiousness,  are 
clinically  the  same  as  in  affections  of  similar  tissues  and  organs  dependent 
on  other  causes.  They  are  consequently  fully  discussed  in  all  modern  works 
on  gynecology. 

Treatment. — The  therapeutics  of  gonorrhea  in  the  female  dtmands 
attention  in  this  work  only  with  respect  to  the  specific  infection  per  se. 

The  treatment  involves  most  of  the  principles  set  forth  in  the  chapter 
on  genito-urinary  and  sexual  hygiene.  Especially  is  rest,  both  sexual  and 
physical,  to  be  enjoined.  The  disease  is  normally  self-limited,  and  if  com- 
plications can  be  prevented,  not  only  is  recovery  likely  to  be  secured  within 
a  reasonable  period,  but  prolonged  infectiousness  may  be  averted.  The 
higher  the  process  extends,  the  more  prolonged  and  insidious  will  be  the 
infection.  The  chief  aim  of  the  surgeon  should  therefore  be  the  prevention 
of  extension  of  the  infectious  inflammation.  Eest  is  the  best  means  of  ac- 
complishing this,  sexual  rest  especially  being  quite  as  important  in  this 
respect  as  in  the  male  when  similarly  infected.  V'aginal  douches  of  potas- 
sium permanganate  1  in  3000  to  1  in  1000  are  a  sine  qua  non.  They  are 
indicated  whether  vaginitis  is  present  or  not,  if  only  to  remove  the  products 
of  infectious  inflammation  as  fast  as  formed,  and  prevent  urethral  infec- 
tion if,  as  is  generally  the  case,  it  has  not  already  occurred.  Although,  as 
has  already  been  remarked,  the  infection  is  usually  above  the  vagina,  the 
permanganate  solution  seems  to  be  of  especial  service.  Whether  more  or 
less  absorption  by  the  vaginal  and  cervical  mucosa  occurs  and  secures 
a  certain  degree  of  germicidal  effect  is  open  to  question.  The  perman- 
ganate irrigations  should  be  given  quite  hot,  slowly,  and  in  large  quantity, 
Avith  the  patient  in  the  recumbent  posture.  Unless  vaginitis  exists  and  be- 
comes chronic,  it  is  hardly  worth  while  to  consider  any  drug  but  the  per- 
manganate for  vaginal  douches  in  gonorrhea.  Mercury  bichlorid  and  silver 
nitrate  are  valuable,  but  by  no  means  to  be  compared  with  the  perman- 
ganate, which  is  the  nearest  approach  to  a  specific  at  our  command. 

Urethritis  and  vesical  complications  demand  balsams  and  alkalies  in- 
ternally, with  the  permanganate  irrigations.  Later  on,  silver-nitrate  irriga- 
tions  may  be  substituted  with  advantage.  Instillations  of  permanganate  or 
silver  solution  with  a  syringe  may  be  useful,  especially  Avhen  the  process 
shows  a  tendency  to  become  chronic. 

Anodynes  and  sedatives  may  be  indicated  in  some  cases,  especially  if 
complications  occur  or  sexual  irritation  be  marked. 

In  chronic  gonorrheal  endocervicitis  and  endometritis  topic  applica- 


TEEATMENT    OF    VAGINITIS.  171 

tions  of  silver,  permanganate,  bichlorid,  iodoform,  and  iodin  may  be  re- 
quired to  effectuall}^  remove  infection.    Curettement  may  even  be  necessary. 

Chronic  vaginitis,  whether  gonorrheal  or  not,  may  often  be  subdued 
by  topic  applications  of  very  strong  silver  solution  or  pure  tincture  of 
iodin  thoroughly  applied  with  a  brush  via  the  speculum. 

The  free  administration  of  saline  laxatives  is  a  most  valuable  measure 
in  gonorrhea  in  women.  Drainage  of  the  peritoneum  is  thereby  secured 
and  is  not  only  curative  iii  case  utero-pelvic  inflammation  supervenes,  but 
prophylactic  as  well.  Another  familiar  method  of  securing  local  deple- 
tion— the  use  of  glycerin — must  not  be  forgotten.  Glycerin  suppositories 
or  injections  in  both  vagina  and  rectum  are  very  serviceable. 

The  more  remote  and  serious  effects  of  gonorrhea  in  women  are  likely 
to  demand  the  knife.  Laparotomy  or  vaginal  section  with  abscess-evacua- 
tion and  drainage,  or  even  removal  of  the  uterus  and  its  appendages,  one 
or  all,  may  eventually  be  required  to  remove  the  source  of  successive  dan- 
gerous reinfections  and  perpetual  invalidism.  Specific  Bartholinitis  is  likely 
to  demand  incision  for  the  cure  of  the  abscess,  followed  by  carbolic-acid  ap- 
plications to  destroy  the  infected  surface;  even  total  extirpation  by  the 
knife  may  be  required. 

The  duration  of  acute  gonorrheal  infection  in  the  female  is  quite  as 
variable  as  in  the  male.  The  more  conscientious  the  application  of  the 
principle  of  rest,  the  more  favorable  will  be  the  progress  of  the  case.  A 
month  in  bed  is  a  by  no  means  too  rigorous  measure.  With  this  prolonged 
period  of  rest,  providing  no  serious  complications  occur,  the  acute  symp- 
toms will  usually  subside  in  from  four  to  six  weeks.  Treatment  should  be 
persisted  in  for  some  time,  however,  to  obviate  possible  autoreinfection. 


CHAPTER  XI. 

Stricture  of  the  Urethra. 

Stricture  of  the  male  urethra  is  the  most  important  of  the  surgical 
diseases  of  the  genito-urinary  apparatus,  not  only  on  account  of  its  extremej 
frequency, — its  special  cause  affecting  sooner  or  later  a  large  proportion  of] 
male  humanity, — but  also  because  of  its  important  relations  to  secondary] 
pathologic  conditions  of  organs  more  vital  than  the  urethra. 

Stricture  of  the  urethra  is  an  abnormal  diminution  of  its  caliber,  tem- 
porary or  permanent,  due  to  any  cause  whatsoever.     It  may  be  caused  byj 
any  of  the  following  conditions: — 

1.  External  pressure,  due  to:    (a)   neoplasms;    (&)   extravasations  oi 
blood  or  urine;    (c)  purulent  collections  and  infiltrations;    (d)  fracture  ofj 
the  pelvic  bones. 

3.  Spasm  of  the  urethral  and  cut-off  muscles,  due  to:    (a)  direct  irrita- 
tion of  the  canal  by  lesions  or  foreign  bodies;   (b)  reflex  irritation  by  foreign] 
bodies  or  remote  pathologic  conditions;   (c)  introduction  of  instruments;  {d)\ 
emotional  excitement;    (e)  malaria  [?];    (/)  highly-acid  and  concentrated] 
urine,  and  occasionally  oxaluria  and  gravel. 

3.  Congestive  or  inflammatory  engorgement  of  the  urethra,  due  to:] 
(a)  acute  urethritis;  (h)  traumatism;  (c)  acute  inflammation  in  and  about] 
organic  obstructions. 

4.  Thickening  of  the  urethral  walls,  due  to:    (a)  congestive  and  granu- 
lar patches, — i.e.,  superficial  infiltration  from  chronic  inflammation;    (6)| 
plastic  infiltration  and  connective-tissue  formation  in  the  corpus  spongiosu] 
from  inflammation;    (c)  traumatic  cicatricial  deposit  in  the  corpus  spon- 
giosum and  urethral  walls;    (d)  cicatricial  deposit  from  caustics  and  power- 
ful irritants;    (e)  cicatricial  deposit  from  ulceration  or  sloughing  producedj 
by  foreign  bodies,  chancre,  chancroid,  or  mucous  syphilides. 

5.  Deficient  elasticity  of  the  urethral  walls  and  corpus  spongiosum: 
(a)  from  congenital  sparsity  of  elastic  and  muscular  fiber  and  a  preponder- 
ance of  fibroconnective  tissue;    (h)  from  chronic  inflammation. 

6.  Congenital  narrowing  of  the  urethra:  atresia  from  defective  fetal 
development. 

7.  Urethral  polypus. 
Strictures  may  be  divided  clinically  as  regards  their  origin  into:    (ij 

congenital;  (2)  acquired,  the  latter  comprising  (a)  traumatic,  (b)  chemicJ 
(c)  acute  inflammatory  or  congestive,  (d)  chronic  inflammator}^,  and  (e)| 
neurotic. 

As  regards  the  essential  condition  producing  obstruction,  they  may  hi 
divided  into:    (1)  spasmodic;  (2)  congestive  or  inflammatory  [circumscribed 

(172) 


SPASMODIC    STKICTUEE.  173 

or  general];    (3)  organic  or  fibrous  [permanent], — i.e.,  inflammatory  neo- 
plastic. 

Strictures,  the  nomenclature  of  which  depends  upon  variation  in  the 
obstructive  conditions,  cannot  always  be  differentiated  clinically;  the  sev- 
eral conditions  may  co-exist  in  varying  proportions.  Thus,  inflammatory  or 
congestive  narrowing  of  the  urethra,  although  often  sufficient  to  produce 
obstruction,  is  generally  associated  with  spasm.  Simple  spasmodic  stricture 
is  relatively  rare,  occurring  only  as  a  result  of  remote  reflex  irritation, 
psychic  impressions,  or  instrumentation  of  a  sensitive  urethra.  On  the 
other  hand,  spasmodic  stricture  dependent  upon  acute  or  chronic  organic 
changes  in  the  urethra  is  frequent.  Again,  there  are  few  cases  of  organic 
stricture  uncomplicated  at  one  time  or  another  by  inflammation,  congestion, 
or  muscular  spasm;  in  fact,  all  of  these  elements — styled  by  the  author 
'•plus  conditions" — and  especially  spasm,  may  require  attention  during  the 
treatment  of  oro-anic  stricture. 


SPASMODIC    STKICTUEE. 

Spasmodic  stricture — or,  more  jDroperly,  pseudostricture — is  a  diminu- 
tion of  urethral  caliber  due  to  spasmodic  contraction  of  the  muscular  fibers 
in  and  about  the  wall  of  the  canal.  Clinical  experience  should  have  taught 
the  surgeon  at  a  very  early  period  the  possibility  of  such  a  condition  as 
spasmodic  stricture,  but  such  was  not  the  case.  The  varying  caliber  of  the 
urethra  during  treatment  for  organic  stricture,  or  during  the  course  of  that 
disease  unmodified  by  treatment,  is  strikingly  suggestive  of  the  element  of 
spasm.  It  will  often  be  found  that  a  stricture  that  will  at  one  sitting  admit 
a  sound  of  fair  size  Avill  at  another  time  only  permit  the  passage  of  a  small 
instnmient  or  perhaps  none  at  all.  Complete  retention  may  occur  at  any 
time  from  acid  urine,  intemperance,  or  sexual  indulgence.  To  be  sure, 
spasmodic  contraction  is  often  associated  with  congestion  and  inflamma- 
tion, but,  even  here,  spasm  is  the  preponderating  condition.  Again,  the 
passage  of  an  instrument  may  be  obstructed  until  after  gentle  pressure, 
when  it  Avill  pass  the  point  of  contraction  quite  readily.  The  grasping  of 
the  instrument  by  the  urethral  walls  in  withdrawal  conclusively  proves  the 
existence  of  spasmodic  contraction. 

Xotwithstanding  the  facility  of  demonstration  of  spasmodic  stricture, 
its  existence  was  not  accepted  until  Hancock  and  Kolliker  demonstrated 
muscular  fibers  in  the  urethral  walls.  Their  researches,  although  valuable, 
unfortunately  led  to  the  belief  that  contraction  of  these  fibers  was  the 
essential  element  of  spasmodic  stricture.  A  comparison  of  the  mechanic 
effects  of  spasmodic  stricture  with  the  power  of  the  muscular  fibers  that  were 
first  supposed  to  be  chiefiy  involved  in  spasm  will  readily  demonstrate  the 
fallacy  of  this  belief.  The  planes  of  muscular  tissue  are  chiefly  longitudinal, 
and  so  sparse  that,  no  matter  how  firmly  contracted,  they  are  incapable  of 


174  STEICTUEE    OF    THE    UEETHKA. 

producing  serious  obstruction.  AVe  must,  therefore,  look  further  for  the 
seat  of  the  spasm,  and  seek  for  structures  the  function  of  wliich  is  to  nor- 
mally obstruct  the  canal  and  prevent  the  escape  of  urine.  A  group  of  such 
structures  is  found  in  the  cut-off  muscle  of  Cruveilhier,  and  it  is  at  a  point 
corresponding  to  this  that  the  principal  spasm  occurs.  The  last  few  drops 
of  urine  or  semen  are  normally  expelled  by  the  accelerator-urince  and  com- 
pressor-tirefhrce  muscles:  the  cut-off  muscle  simultaneously  closes  the  deep 
urethra:  i.e.,  the  vesical  neck.  Spasmodic  stricture  is  a  mere  exaggeration 
of  this  physiologic  function,  in  which,  from  irritation,  the  muscle  is  spas- 
modically contracted  and  the  volitional  power  of  urination  temporarily  in- 
hibited. The  accelerator-urince  and  compressor-urefhrce  muscles  play  only 
a  minor  part  in  such  spasm,  the  chief  factor  being  the  contraction  of 
the  voluntarv  cut-off  muscle.     A  certain  amount  of  spasm  produced  by 


B 


Fig.  51. — Showing  the  manner  in  which  urethral  coarctation  and  spasm 
opix)se  the  entrance  and  withdrawal  of  a  bulbous  bougie.  A,  Shoulder 
of  bulb  caught  at  stricture.  B.  Opposing  urethral  walls  in  front  of 
stricture. 

contraction  of  the  circular  fibers — compressor-urefJircB  muscle — may  occur 
anywhere  in  the  canal.  This  explains  in  part  obstruction  to  instrumenta- 
tion in  penile  strictures  of  large  caliber.  This  spasm  also  facilitates  explora- 
tion with  bulbous  instruments.  It  is  by  spasmodic  contraction  that  the 
sensitive  urethra  resents  at  diseased  points  the  passage  of  the  bulb,  thus 
giving  evidence  of  obstruction. 

LocATiox  or  Spasmodic  Stricture. — There  are  nearly  always  two 
points  of  spasm:  (a)  the  seat  of  irritation  and  (&)  the  musculo-membranous 
region. 

1.  ^Tien  a  foreign  body  is  introduced  the  urethra  resents  its  presence 
by  contraction  at  the  point  of  irritation,  and  simultaneously  by  reflex  spasm 
of  the  cut-off  muscle.  The  same  holds  true  in  penile  organic  stricture, 
especially  those  at  the  meatus.    Instruments  produce  stretching  and  irrita- 


SPASMODIC    STEICTUKE.  175 

tion  of  the  lesion  in  the  anterior  portion,  refiexly  exciting  spasm  of  the 
deep  urethra;  so  that  in  a  large  proportion  of  cases  of  stricture  there  are 
at  least  two  points  of  obstruction:  one  at  the  diseased  point  impinged  upon 
by  the  instrument,  and  another  in  the  deep  urethra.  The  same  phenomenon 
results  Avhen  the  anterior  obstruction  is  a  congenital  stricture  or  point  of 
normal  contraction.  This  is  important,  for,  simultaneously  with  the  re- 
moval of  the  anterior  point  of  obstruction  and  irritation,  the  supposed  deep 
organic  stricture  usually  disappears. 

2.  The  entire  canal  may  be  spasmodically  contracted  and  resent  the 
introduction  and  withdrawal  of  instruments. 

3.  The  musculo-membranous  region  ma}^  alone  be  involved.  This  hap- 
pens where  an  organic  lesion  exists  in  the  deep  urethra  and  also  in  reflex 
spasm. 

Etiology.- — Predisposing  Causes. — (a)  General  hyperesthesia;  (b)  local 
hyperesthesia.  These  conditions  are  modified  by  a  nervous  temperament, 
debility  and  cachexia,  the  rheumatic  and  gouty  diatheses,  intemperance, 
high  living,  faulty  sexual  hygiene,  etc.  (c)  Acute  or  chronic  genito-urinary 
disease.  This  is  the  most  frequent  predisposing  cause;  indeed,  spasmodic 
stricture  is  rarely  met  with  where  a  more  or  less  damaged  urethra  does  not 
exist.  So  uniformly  is  it  present  that  it  is  always  to  be  suspected  until 
organic  disease  has  been  excluded  by  exploration.  Congested  and  f ungating 
patches,  mucous  erosions,  acute  and  chronic  urethritis,  and  organic  stricture 
predispose  to  spasmodic  contraction,  both  at  the  point  of  irritation  and  at 
the  cut-oif  muscle.  Congenital  narrowing  of  the  meatus  or  other  parts  of 
the  canal  may  give  rise  to  reflex  spasm  of  the  deep  urethral  muscles  when- 
ever an  instrument  is  passed  of  sufficient  size  to  produce  stretching  of  the 
sensitive  tissues  at  the  point  of  contraction.  As  already  noted,  when  in- 
struments are  introduced  under  these  conditions  there  is  spasm  at  the  site 
of  the  lesion  and  also  deep  in  the  canal. 

3.  Exciting  Causes.  —  (1)  Passage  of  instruments;  (2)  sexual  excite- 
ment or  excess;  (3)  urethral  injury,  chemic  or  traumatic;  (4)  a  debauch; 
(5)  cold-taking;  (6)  foreign  bodies;  (7)  drugs,  such  as  cantharides  and  tur- 
pentine;   (8)  reflex  irritation;    (9)  malaria  [?];    (10)  mental  emotions. 

In  surveying. the  various  exciting  causes  of  spasmodic  stricture  it  will 
be  observed  that  in  nearly  all  instances  spasm  is  associated  with  congestion 
or  inflammation:  conditions  that  such  special  causes  are  most  apt  to  de- 
velop. Spasm  due  to  drugs  is  usually  associated  with  considerable  inflam- 
mation, with  frequent  and  painful  micturition,  and  possibly  urethral  hem- 
orrhage. The  most  frequent  exciting  causes  are  intemperance,  exposure  to 
cold  and  wet,  and  sexual  excess.  Highly-acid  urine  in  gouty  patients  is 
said  to  act  as  an  exciting  cause  per  se,  but  it  is  doubtful  if  such  a  condition 
of  the  urine  can  cause  obstructive  spasm  in  a  healthy  urethra.  Again,  the 
existence  of  a  perfectly  sound  urethra  in  gouty  patients  is  open  to  ques- 
tion.   Acid  urine  is  an  important  element  in  spasm  due  to  excesses  of  vari- 


176 


STEICTrKE    OF    THE    UEETHEA. 


ous  kinds  and  cold-taking  superadded  to  organic  disease.  Instrumentation 
of  a  sensitive  canal,  especially  if  organic  disease  exists,  is  likely  to  develop 
spasmodic  stricture,  which  may  last  for  some  days  or  weeks. 

Cases  of  intermittent  spasm  due  to  malaria  and  curable  by  quinin  are 
recorded,  but  it  is  questionable  whether  malaria  alone  can  act  directly  as 
an  exciting  cause;   that  it  may  predispose  to  spasm  is  admitted. 

In  passing  instruments  into  the  virgin  urethra,  and  in  delicate  and 
nervous  patients, — whether  organic  disease  exists  or  not, — the  instrument 
is  apt  to  be  obstructed  by  spasm  in  the  deep  urethra.  The  obstruction 
generally  gives  way  under  gentle,  continous  pressure  with  the  beak  of  the 
instrument.  In  withdrawing  the  instrument  a  sense  of  biting  or  grasping, 
upon  it  is  felt  by  the  operator;  the  patient  may  herself  experience  a  sen- 
sation of  urethral  traction. 

It  is  a  common  observation  that  some  individuals  cannot  urinate  in 
the  presence  of  others.  This  is  usually  regarded  as  spasmodic  stricture  from 
mental  emotion,  but  is  jarobably  due  to  psychic  inhibition  of  volitional 
power  over  the  cut-off  muscle  and  the  normal  involuntary  contraction  of 
the  detrusor  tirince,  rather  than  to  spasm. 

Eeflex  spasm  of  the  cut-off  muscle  most  often  arises  from  irritation  of 
structures  bearing  a  direct  relation  to  the  genito-urinary  tract  through  com- 
munit}'  of  nervous  supply;  diseases  of  the  bladder,  kidneys,  rectum,  and 
anus  are  very  apt  to  produce  it.  Retention  is  not  uncommon  after  forcible 
stretching  of  the  sphincter  ani  in  operations  for  hemorrhoids,  fistula  in  ano, 
and  rectal  stricture.  Inflammation  in  and  about  the  perineum  may  pro- 
duce retention  through  spasm,  independenth'  of  pressure. 

The  possible  occurrence  of  deep  spasmodic  stricture  should  be  consid- 
ered in  every  vesico-urethral  disease.  The  point  from  which  irritation  is 
reflected  may  be  above  or  below  the  site  of  spasm — -i.e.,  the  perineo-urethral 
muscles. 

The  urinary  flow  may  be  greatly  lessened  during  a  gonorrhea,  and  yet 
be  sufficient  for  physiologic  needs,  when  suddenly  retention  occurs  and  this 
without  extension  of  infiammation  to  the  deep  urethra  or  bladder.  Such 
retention  usually  means  a  deep  extension  of  inflammation,  but  the  reten- 
tion is  not  so  sudden,  and  is  preceded  by  symptoms  of  prostatic  or  vesical 
irritation.  In  chronic  prostatitis  and  cystitis  with  or  without  calculus  sud- 
den retention  may  occur.  Congestion  is  the  primal  cause  of  obstruction  in 
such  cases,  but  it  is  the  reaction  of  the  muscular  structures  to  irritation 
that  brings  about  the  sudden  and  final  occlusion  of  the  urinary  way.  Spasm 
plays  the  principal  role  and  congestion  the  preparatory. 

In  prostatic  hypertrophy  the  least  disturbance  of  the  usual  regimen  or 
the  slightest  venereal  or  dietetic  excess  or  exposure  causes  congestion  of 
the  deeper  parts  of  the  urethra.  This  may  excite  reflex  contraction  of  the 
surrounding  muscles,  with  consequent  retention. 

Some  interesting  examples  have  been  cited  where  irritation  of  neigh- 


SPASMODIC    STRICTURE.  177 

boring  parts  has  produced  spasmodic  retention.  Thus,  le  Dentu  cites  a  case 
of  testicular  neuralgia  the  exacerbations  of  which  were  accompanied  by 
spasmodic  retention.  He  also  calls  attention  to  the  providential  spasmodic 
retention  that  often  prevents  urinary  extravasation  in  wounds  of  the  ure- 
thra and  perineum. 

Uterine  affections  have  been  known  to  cause  spasmodic  retention,  and 
it  is  probable  that  post-partum  retention  often  has  a  strong  spasmodic 
element. 

It  has  been  held  that  injuries  of  parts  very  remote  from  the  urinary 
apparatus  .may  produce  spasmodic  retention;  thus,  a  fall  upon  the  knees, 
fractures  of  the  ribs,  surgical  operations  (such  as  laparotomy),  and  many 
other  accidents  of  a  traumatic  character  are  sometimes  associated  with  re- 
tention. It  is  doubtful  if  this  retention  is  due  to  spasm.  Inhibition  of  the 
detrusor  urinse  or  of  volitional  power  over  the  cut-off  muscle,  due  to  shock, 
commotio  cerebri,  or  commotio  spinalis  seems  a  more  logical  explanation. 
There  may,  however,  be  apparent  retention — i.e.,  suppression — due  to  reflex 
inhibition  of  renal  secretion,  especially  after  abdominal  operations.  Ob- 
tunding  of  vesical  sensation  from  shock  or  concussion  may  have  much  to 
do  with  the  temporary  retention.  In  slighter  cases  exaltation  of  emotional 
sensibility  may  be  a  causal  factor.  A  patient  who  has  been  operated  upon 
or  seriously  injured  and  is  compelled  to  use  a  duck  or  bed-pan,  often  with 
an  attendant  close  at  hand,  sometimes  experiences  a  temporary  inhibition 
of  voluntary  control  over  the  cut-off  muscle. 

Urethrismus,  or  chronic  spasmodic  stricture,  is  occasionally  seen.  This 
condition  may  result  from  various  more  or  less  remote  sources  of  irritation. 
It  may  be  caused  by  chronic  abscesses  in  and  about  the  genito-urinary 
organs.  Fessenden  Otis  has  reported  a  very  interesting  case  of  this  kind 
due  to  fistula  and  chronic  abscess  of  the  scrotum  and  testicles. 

Dr.  Otis's  remarks  anent  urethrismus  are  worth  repetition: — 

The  term  spasmodic  stricture  has  usually  been  applied  to  all  temporary  con- 
tractions of  the  urethra  which  interfere  in  any  degree  with  either  the  passage  of 
instruments  into  the  bladder  or  the  voluntary  discharge  of  urine  from  it.  As  thus 
understood,  it  has  been  described  as  varying  in  degree  from  the  slight  localized  mus- 
cular spasm,  which  but  momentarily  arrests  the  progress  of  an  ingoing  instrument, 
to  the  firm,  close  contraction  which  more  or  less  persistently  resists  its  introduction 
in  skilled  hands,  or  from  that  which  occasionally  diminishes  the  strength  of  the 
outgoing  stream  of  urine  in  urination  to  that  producing  complete  and  enforced 
retention  of  urine. 

In  whatever  degree  present  in  any  case,  it  is  claimed  by  all  authorities  to  be 
characterized  by  its  transient  duration  and  its  ready  yielding  to  remedial  measures. 
In  accordance  with  this  teaching,  all  permanent  or  habitual  interference  with  urina- 
tion or  the  passage  of  instruments  (except  in  some  rare  instances  complicated  by 
vesical  paralysis)  must  have  an  organic  cause,  and  depend  either  upon  the  presence 
of  an  intravesical  growth,  an  enlarged  prostate,  or  close  organic  stricture.  It  is  also 
within  the  experience  of  many  surgeons  to  see  supposed  cases  of  close  organic  stricture 
placed  upon  the  operating-table  for  the  performance  of  external  perineal  urethrotomy. 


178  STRICTUEE    OF    THE    UEETHKA. 

which,  when  fully  anesthetized,  astonish  the  operator  by  permitting  the  full-sized 
exploratory  staff  to  slip  easily  into  the  bladder.  In  other  cases  the  entire  absence  of 
that  peculiar  resistance  to  the  knife  which  the  experienced  surgeon  recognizes  when 
dividing  cicatricial  tissue,  and  the  failure  to  locate  with  exactness  the  contracted 
point,  will  suggest  to  the  memory  of  some  that  occasional  patients,  similarly  affected, 
have  not  escaped  so  easily. 

Not  infrequently  persistent  difficulty  in  urination  and  perhaps  retention  of  urine 
requiring  the  habitual  use  of  the  catheter  has  been  observed  by  surgeons  where  no 
proofs  of  intravesical  growths  were  present,  and  where  the  easy  passage  of  an 
ordinary  catheter  jjrecluded  the  idea  of  enlargement  of  the  prostate  or  of  close 
organic  stricture. 

If  it  can  be  proved  that  purely  spasmodic  urethral  contraction  may,  and  not 
infrequently  does,  present  all  of  the  important  diagnostic  features  of  the  true  close 
organic  stricture,  and,  further,  if  it  can  be  shown  that  polypoid  and  prostatic  obstruc- 
tion are  often  simulated  by  chronic  spasm  of  the  accelerator-urinse  muscles,  pro- 
ducing obstruction  and  persistent  closure  of  the  membranous  urethra,  then  it  will 
be  conceded  that  failure  to  appreciate  so  important  a  complication  will  conduce  to 
grave  errors  in  diagnosis,  terminating  possibly  in  an  operation  for  conditions  which 
exist  only  in  the  mind  of  the  surgeon. 

It  must  at  once  be  apijarent  to  every  surgeon  of  experience  that  Dr. 
Otis  has  given  us  in  the  foregoing  remarks  a  most  valuable  and  practically 
reliable  principle  in  genito-urinary  surgery.  So  evident,  too,  is  the  point 
involved  that  it  is  remarkable  that  it  remained  for  him  to  discover. 

In  a  large  proportion  of  penile  strictures  a  sound  large  enough  to  put 
the  contraction  on  the  stretch  either  will  not  enter  the  bladder  or  does  so 
with  great  difficulty.  A  bulbous,  flexible  bougie  of  any  size  will  not  enter 
at  all,  and,  even  if  a  small  one  does  pass  the  deep  urethra,  it  is  firmly  grasped 
on  withdrawal,  the  sensation  imparted  to  the  hand  being  not  always  decep- 
tive to  the  expert,  but  to  the  surgeon  of  little  or  moderate  experience  consti- 
tuting irrefutable  evidence  of  deep  organic  stricture. 

The  association  of  spasmodic  contraction  of  the  deep  urethral  muscles 
with  renal  disease  has  not  received  special  attention.  It  is  an  element,  how- 
ever, of  the  painful  and  frequent  micturition  incidental  to  nephric  stone 
and  pyelitis.  The  author  has  a  case  now  under  observation  in  which  there 
was  marked  urinary  obstruction  coincident  with  an  acute  exacerbation  of 
pyelitis,  although  the  urethra  had  previously  been  entirely  free  from  ob- 
struction. In  such  cases  there  may  be  associated  with  the  spasm  more  or 
less  reflex  neuralgic  pain  in  the  back,  groins,  hypogastrium,  and  thighs. 
It  should,  of  course,  be  remembered  that  there  exists  in  these  cases  a  special 
irritating  factor:   i.e.,  morbid  urine. 

Diagnosis. — The  diagnosis  of  spasmodic  stricture  is  usually  easy,  espe- 
cially where  retention  occurs  suddenly.  It  is  obvious  that  the  sudden  oc- 
currence of  retention  in  organic  stricture  or  other  obstructive  lesion  of  the 
genito-urinary  tract,  in  which  the  stream  of  urine  has  previously  been  fairly 
free,  must  depend  upon  some  complication — either  inflammation  and  con- 
gestion at  the  site  of  the  organic  lesion  or  spasmodic  contraction  of  the  cut- 


SPASMODIC    STEICTUEE.  1?9 

off  muscle,  or  the  two  combined.  Inflammation  or  congestion  is  to  be  in- 
ferred in  every  case  of  spasmodic  retention,  and  demands  due  consideration ; 
the  predominating  element  of  spasm  is,  however,  the  principal  feature. 
As  a  rule,  in  cases  of  sudden  retention  of  this  kind  there  is  a  histor}^  of  some 
one  or  more  of  the  exciting  causes  that  have  been  enumerated. 

In  the  diagnosis  of  spasmodic  retention  it  should  be  remembered  that 
in  by  far  the  majority  of  cases  there  is  some  organic  foundation  for  the  con- 
dition. When,  in  the  course  of  treatment  for  organic  stricture  of  small 
caliber,  retention  suddenly  occurs,  the  predominating  condition  is  usually 
congestion  or  inflammation.  The  occurrence  of  acute  urethritis  during  the 
course  of  organic  stricture  is  likely  to  superinduce  sudden  retention.  The 
condition  in  these  cases,  although  a  spasmodic  element  exists,  is  mainly  con- 
gestion and  inflammation  at  the  site  of  the  stricture  producing  sufficient 
swelling  to  completely  occlude  the  urethra  for  the  time  being.  Traumatic 
urethritis  causes  retention  in  the  same  way.  In  strictures  of  large  caliber 
in  which  the  passage  of  urine  is  comparatively  free,  spasmodic  retention 
may  suddenly  develop.  It  is  doubtful  whether  congestion  or  inflammation 
alone  could  produce  complete  closure  of  the  canal  in  such  cases. 

It  is  sometimes  difficult  to  determine  during  instrumentation  what 
proportion  of  the  obstruction  is  due  to  organic  contraction  and  what  to 
spasm.  For  example,  after  an  instrument  has  passed  a  stricture  of  large 
caliber  in  the  penile  portion  of  the  urethra,  or  an  inflamed  and  irritable 
meatus,  it  will  often  be  obstructed  on  entering  the  membranous  region.  A 
steel  sound  is  less  likely  to  be  obstructed  than  a  soft  bulbous  bougie,  and 
the  spasm  is  more  likely  to  yield  to  steady  and  gentle  pressure  with  the 
point  of  the  sound  than  to  a  soft  bulb.  If  there  is  a  slight  organic  con- 
traction at  the  bulbo-membranous  Junction,  a  steel  instrument  small  enough 
to  pass  the  stricture  in  the  anterior  portion  of  the  canal  will,  in  all  prob- 
ability, slip  by  the  deeper  constriction  and  fail  to  detect  it.  A  large  bulbous 
instrument  usually  fails  to  pass  altogether,  but  if  a  small  bulbous  bougie 
be  introduced,  it  will  be  found  that  the  spasm  of  the  surrounding  muscles, 
although  not  sufficient  to  prevent  the  instrument  from  entering  the  bladder, 
will  contract  the  stricture  so  that  the  shoulder  of  the  bulb  catches  upon  it 
as  it  is  withdrawn.  The  peculiar  feel  imparted  to  the  bougie  and  the  sud- 
den snap  produced  by  the  passage  of  its  shoulder  through  the  organic  con- 
traction will  show  the  character  of  the  case. 

It  will  thus  be  seen  that  a  comparatively  small  bulb  may  detect  an 
organic  contraction  with  predominating  spasm  in  the  deep  urethra  where  a 
steel  sound  of  considerable  size  would  fail.  The  peculiar  sense  of  elasticity 
imparted  to  the  instrument  as  it  presses  against  the  portion  of  the  urethra 
spasmodically  contracted  gives  the  expert  a  tolerably  accurate  idea  of  the 
real  condition  of  affairs.  Because  of  the  spasm  usually  encountered  there 
are  few  individuals  in  whom  deep  stricture  cannot  be  demonstrated  by  a 
bulb.     If,  however,  a  very  small  bulbous  instrument  be  passed  and  slowly 


180  STRICTUEE    OF    THE    URETHEA. 

withdrawn^,  organic  contraction  can  usually  be  excluded.     The   ordinary 
sound  cannot  be  relied  upon  for  a  diagnosis. 

Exceptional  cases  of  chronic  spasmodic  stricture  are  met  with  in  which 
the  real  condition  can  only  be  demonstrated  after  the  subtraction  of  alli 
sources  of  irritation,  direct  or  reflex,  when  the  supposed  organic  stricture 
disappears. 

Eeferring  to  spasm  in  the  penile  urethra,  it  is  important  to  know  that 
in  many  cases  denominated  penile  "stricture  of  large  caliber"  the  urethra  isj 
not  organically  strictured,  but  as  instruments  pass  over  a  thickened,  granu- 
lar, and  hyperesthetic  patch  there  occurs  at  the  site  of  the  lesion,  spasm  of] 
the   accelerator-urinm  and  compressor-urethrce  muscles,   giving  rise  to  thej 
same  objective  symptoms  as  organic  stricture.    It  is  probable  that  urethrot- 
omy is  often  performed  where  true  organic  obstruction  does  not  exist,  the! 
condition  just  described  explaining  the  obstruction  to  instruments  and  the 
grasping  of  the  bulb  as  it  is  withdrawn.     This,  however,  is  not  necessarily] 
an  argument  against  the  necessity  for  urethrotomy. 

Teeatment.  —  The   first   indication   in   the   treatment   of   spasmodic  j 
stricture  is  the  removal  of  all  predisposing  causes  so  far  as  possible.     Such  I 
conditions  as  the  gouty  and  rheumatic  diathesis  require  correction.     Gen- 
€ral  nervous  irritability  and  hyperesthesia  demand  nervine  tonics,  sedatives,] 
or  antispasmodics,   according  to   special  indications.     The  principles   ofj 
genito-urinary  and  sexual  hygiene  should  be  thoroughly  impressed  upon 
the  patient's  mind.    Once  he  is  convinced  of  the  fallacy  of  the  notion  that 
his  penis  and  testes  are  the  axis  of  his  earthly  existence,  the  surgery  of  the] 
case  is  much  simplified.    All  sources  of  local  and  reflex  irritation  must  bej 
removed.    This  necessarily  involves,  as  a  rule,  the  cure  of  organic  urethral 
lesions.     The  urine  should  be  kept  bland  and  non-irritating  by  dietetic 
measures  and  the  administration  of  alkaline  remedies.    Careful  study  should 
be  given  to  the  degree  of  tolerance  of  the  urethra  for  instruments.     The 
amount  of  irritability  of  the  urethra  and  the  degree  of  spasm  excited  by. 
instrumentation  constitute  a  fair  criterion  of  the  frequency  with  which] 
they  should  be  introduced  in  the  treatment  of  organic  stricture. 

In  spasmodic  retention  an  attempt  should  be  made  to  relieve  the  con- 
dition by  derivation — to  remove  possible  congestion — and  antispasmodics. 
The  passage  of  instruments  should  be  avoided,  if  possible,  as  tending  to  in- 
crease irritation  and  spasm.     The  full  hot  bath  and  morphia  by  the  mouth] 
or  hypodermically  should  be  depended  upon  so  far  as  practicable.     The 
patient  often  succeeds  in  passing  urine  while  in  the  hot  bath,  which  is  both 
derivative  and  sedative.     When  these  simpler  measures  fail,  a  small  soft] 
catheter  should  be  passed, — -while  the  patient  is  in  the  bath,  if  possible. 
Chloroform  or  ether  may  be  given  to  the  extent  of  full  anesthesia,  if  neces-j 
sary,  to  relax  the  spasm  and  facilitate  instrumentation.     When  retention! 
comes  on  in  organic  stricture,  it  must  be  remembered  that  it  is  not  due  to  I 
organic  contraction  per  se,  but  to  certain  plus  conditions:    i.e.,  spasm,  con- 


CONGESTIVE    STEICTUEE.       OEGAXIC    STKICTUEE.  181 

gestion,  and  edema  of  tissue  in  varying  proportions.  Eelief  of  retention 
depends  upon  the  subtraction  of  these  plus  conditions  from  the  primary 
predisposing  factor  of  organic  contraction.  The  treatment  of  urethrismus 
is  chiefly  operative.  After  all  sources  of  reflex  irritation  have  been  removed 
the  urethrismus  disappears. 

CONGESTIVE^    OE   INFLAMMATOEY,    STEICTUEE. 

This  is  usually  a  complication  rather  than  a  distinct  pathologic  entity^ 
being  even  less  frequently  met  with  as  a  primary  condition  than  spasm. 
Its  existence  as  an  essential  condition  is  denied  by  many  surgeons,  but  it 
nevertheless  appears  to  be  the  main  feature  of  a  minor  proportion  of  cases 
of  urinary  obstruction  with  or  without  retention.  Congestive,  or  inflam- 
matory, obstruction  may  occur:  (1)  as  the  result  of  occlusion  of  the  ure- 
thra by  extensive  infiltration  of  the  mucous  membrane,  periurethral  con- 
nective tissue,  and  corpus  spongiosum  in  severe  or  virulent  urethritis;  (2) 
at  the  site  of  injury  to  the  mucous  membrane  produced  by  instrumental  or 
accidental  trauma;  (3)  as  a  consequence  of  acute  urethritis  afEecting  strict- 
ures of  large  caliber  or  congested  and  granular  patches  of  mucous  mem- 
brane. 

Congestive,  or  inflammatory,  stricture  necessarily  occurs  most  fre- 
quently in  connection  with  organic  stricture.  It  is  often  difficult  to  de- 
termine in  a  particular  case  exactly  what  relative  proportions  of  spasm  and 
congestion  exist. 

Some  cases  of  congestive  stricture  are  of  a  chronic  type,  and  exhibit  a 
marked  tendency  to  hemorrhage,  from  instrumental  interference,  sexual 
indulgence,  or  in  rare  instances  without  apparent  cause.  The  author  has 
noticed  this  symptom  with  especial  frequency  in  syphilitics  and  patients 
having  a  tendency  to  varices. 

Teeatment. — The  therapeutic  indications  are  the  same  as  in  spas- 
modic stricture, — which  is  usually  a  complicating  factor, — excepting  that 
in  cases  in  which  congestion  is  believed  to  be  a  prominent  element  the  ap- 
plication of  leeches  in  the  course  of  the  urethra,  particularly  in  the  perineal 
region,  is  advisable. 

OEGANIC    STEICTUEE. 

Organic,  permanent,  or  fibrous  stricture  is  a  contraction  of  the  urethra 
produced  by  localized  adventitious  tissue-formation,  either  congenital  or 
acquired.  It  is  usually  acquired  and  most  frequently  met  with  between 
the  ages  of  twenty-four  and  forty-five. 

Stricture  very  rarely  gives  trouble  for  the  first  time  after  the  age  of 
forty.  It  may  occur  at  any  time  after  the  period  of  puberty,  perhaps  before 
puberty,  if  traumatic.  The  frequency  of  stricture  between  the  ages  men- 
tioned is  easily  explained  by  the  fact  that  it  is  at  this  period  of  life  that 
urethritis — the  most  frequent  cause  of  stricture — is  most  likely  to  occur. 


182 


STEICTUEE    OF    THE    UKETHBA. 


Teaumatic  Steictuee. — Traumatic  organic  stricture  may  occur  at  any 
age.  The  youngest  ease  that  has  come  under  the  authors  observation  was 
a  boy  of  13,  who  was  operated  upon  by  external  perineal  section.  In  this 
case  the  stricture  recontracted, — probably  from  neglect  on  the  patient's  part, 
—and  is  now  with  difficulty  kept  open.  Another  operation  will  be  eventu- 
ally required.,   Erichsen  records  a  case  in  a  boy  11  yeaTs  of  age. 

Traumatic  stricture  is  usually  located  at  the  triangular  ligament.     It; 
is  here  that  the  urethra  is  most  likely  to  be  injured  by  blows  or  falls.     A| 
fall  astride  a  hard  object  or  a  kick  in  the  perineum  is  the  usual  cause. 
The  bulbo-membranous  urethra  is  caught  between  the  impinging  body  and' 
the  sharp,  knife-like  lower  border  of  the  subpubic  ligament,  and  a  very 
slight  degree  of  force  may  therefore  produce  permanent  injury.    It  does  not 
require  great  violence  to  sever  completely  the  deep  urethra.    The  pendulous 
urethra,  on  the  other  hand,  is  rarely  involved  on  account  of  the  difficulty 
with  which  it  can  be  caught  between  two  impinging  bodies. 

Whatever  the  location  of  traumatic  stricture,  it  is  composed  of  cica- 
tricial tissue,  the  extent  of  which  depends  upon  the  degree  of  destruction 
of  the  urethral  walls  that  has  given  rise  to  the  stricture.  Obviously,  such 
a  stricture  is  the  worst  with  which  we  have  to  deal.  It  is  rarely  amenable 
to  dilation  and  usually  requires  perineal  section. 

Congenital  Steictuee. — Narrowing  of  the  meatus  aside,  the  con-' 
genital  form  of  stricture  is  rare.  The  occurrence  of  congenital  stricture 
below  one-fourth  of  an  inch  from  the  meatus  is  denied  by  most  authorities. 
If,  however,  we  take  into  consideration  the  occasional  occurrence  of  con- 
genital atresia  of  a  part  or  the  whole  of  the  urethra,  the  possible  occur- 
rence of  localized  congenital  narrowing  of  the  canal  is  readily  understood. 
The  author  has  seen  a  number  of  cases  of  linear  stricture  of  the  pendulous 
portion  of  the  canal  that  he  believes  to  have  been  of  congenital  origin.  It' 
may  be  asserted  that  such  cases  are  traumatic,  or  due  to  the  mechanic 
irritation  produced  by  masturbation.  The  possibility  of  this  is  admitted. 
In  speaking  of  congenital  stricture  points  of  slight  relative  contraction 
that  may  be  demonstrated  in  most  subjects  are  not  included. 

Congenital  stricture  of  the  meatus  is  a  relative  matter,  inasmuch  as  it' 
is  not,  pe7-  se,  productive  of  discomfort  in  the  majority  of  cases.     A  meatus: 
narrower  than  the  average  is  not  likely  to  be  annoying,  providing  gonor- 
rhea is  not  contracted. 

As  already  noted,  the  size  of  the  meatus  varies  greatly  in  different] 
individuals,  and  there  is  very  frequently  not  only  a  narrow  meatus,  but 
a  distinct  linear  contraction  of  the  canal  about  one-fourth  of  an  inch  within] 
it.  When  such  a  urethra  becomes  affected  by  inflammation,  or  when  it  is 
found  necessary  to  explore  the  urethra  or  bladder,  the  meatus  at  once 
assumes  a  position  of  pathologic  importance,  inasmuch  as  it  is  impossible 
to  satisfactorily  explore — and  more  difficult,  if  possible,  to  thoroughly  treat] 
— a  urethra  of  moderately  large  caliber  through  a  narrow  meatus. 


OKGANIC    STKICTUEE.  183 

In  order  to  acc-urateW  determine  the  condition  of  the  urethra  or  treat 
oroanic  disease  of  the  mucous  membrane  the  meatus  must  admit  instru- 
ments of  a  size  corresponding  to  the  largest  mean  diameter  of  the  canah 
Obviously,  when  the  normal  caliber  of  the  urethra  is  38  French,  it  is  im- 
possible to  satisfactorily  explore  or  treat  it  when  the  extreme  capacity  of 
the  meatus  is  only  30  French.  Otis's  urethrometer  in  the  hands  of  the 
expert  has  obviated  the  difficulty  of  exploration  in  such  cases,  to  a  certain 
extent,  but  it  is  by  no  means  so  satisfactory  or  safe  for  routine  use  as  the 
bulbous  bougie.  AVhenever,  therefore,  there  exists  a  suspicion  of  urethral, 
prostatic,  or  bladder  disease  and  the  meatus  is  contracted,  it  should  be 
enlarged  by  incision  sufficiently  to  admit  an  instrument  that  will  thoroughly 
distend  the  canal. 

In  quite,  a  number  of  instances  a  contracted  meatus  has  been  known 
to  induce  reflex  neurotic  disturbances.  Vesical  irritability,  with  frequent 
micturition,  and  perhaps  more  suspicious  symptoms  of  stone,  have  been 
known  to  arise  from  this  cause.  The  author  has  met  with  a  number  of 
cases  of  this  character,  and  one  more  interesting  still  in  which  atony  of 
the  bladder  resulted,  as  was  demonstrated  by  the  cure  that  followed  mea- 
totomy. 

Congenital  narrowing  of  the  meatus  may  be  due,  as  already  mentioned 
in  connection  with  the  anatomy  of  the  urethra,  to  partial  occlusion  by  a 
thin  membranous  septum  at  its  inferior  commissure,  the  fossa  navicularis 
terminating  in  a  pouch  behind  it.  In  others,  however,  the  narrowing  is 
due  to  exceptional  thickness  of  the  tissues  of  the  glans  below  the  meatus. 
In  the  former  the  meatus  may  stretch  easily  when  instruments  are  passed; 
in  the  latter,  however,  the  introduction  of  an  instrument  of  sufficient  size 
to  distend  the  meatus  produces  spasm,  in  some  cases  of  the  entire  canal, 
always  of  the  cut-off  muscle.  It  will  be  seen,  therefore,  that  it  is  not  alone 
the  size  of  the  meatus  which  is  important,  but  also  its  dilatability  and 
degree  of  tolerance  of  instrumentation.  Whenever,  during  the  passage 
of  an  instrument,  the  meatus  is  drawn  tightly  above  it  in  a  thin  white  line, 
it  is  safe  to  conclude  that  that  particular  instrument  cannot  be  introduced 
into  the  deep  urethra  without  unwarrantable  force. 

Ueetheal  Steictuee  in  the  Female. — The  female  sex  enjoys  rela- 
tively great  immunity  from  urethral  stricture.  This  is  explicable  by  the 
shortness  and  simple  structure  of  the  canal  and  the  extreme  rarity  of 
urethritis  in  the  female.  The  author  has  never  seen  but  three  cases  of  the 
kind;  one  of  these  occurred  in  a  masturbator,  probably  from  laceration  by 
the  introduction  of  foreign  bodies.  Erichsen  records  a  case  in  a  woman, 
but  does  not  state  the  probable  cause.  Eecent  contributions  to  surgical 
literature,  however,  have  shown  that  stricture  in  the  female  is  more  frequent 
than  is  generally  supposed.  Van  de  AVarker  has  reported  a  number  of  in- 
teresting cases. 

Otis  has  also  observed  that  stricture  of  the  urethra  is  more  often  seen 


184 


STEICTITEE    OF    THE    UKETHRA. 


in  women  than  is  generally  believed.  Symptoms  that  in  men  would  be  at 
once  attributed  to  stricture  of  the  urethra  are  most  often  attributed  in 
women  to  an  irritable  bladder.  It  has  been  asserted  that  stricture  may 
occur  in  lithemic  female  patients  independently  of  inflammation,  specific 
or  otherwise,  and  require  the  same  treatment  as  in  men. 

Vaeieties  of  Organic  Steicture. — Organic  acquired  stricture  occurs 
in  three  principal  varieties  as  regards  conformation:  1.  The  first  and 
simplest  is  the  linear  stricture,  the  resulting  obstruction  corresponding 
to  that  which  would  be  produced  by  tying  a  narrow  cord  about  the  canal. 
2.  The  second  variety,  annular  stricture,  is  wider,  the  condition  being  me- 
chanically similar  to  that  which  would  result  from  tying  a  piece  of  tape 
about  the  canal.    3.  The  third  form,  tortuous  stricture,  has  been  needlessly 


Fig.  52. — Linear  stricture.     (After  Voillemier. 


divided  into  numerous  subvarieties.  It  involves  a  considerable  extent  of  the 
urethra  in  an  irregular  contraction.  For  practical  purposes  these  three 
varieties  are  sufficiently  distinctive. 

Strictures  may  be  classified  clinically  as:  (a)  simple  and  readily  di- 
latable; (h)  irritable,  involving  local  hyperesthesia  and  hyperemia;  (c)  re- 
silient or  elastic;  (d)  recurrent.  This  classification  of  stricture  necessarily 
depends  largely  upon  its  behavior  under  treatment. 

Linear  strictures  appear  in  several  different  forms.  There  may  be  one 
or  more  membranous  septa  encroaching  on  the  caliber  of  the  canal.  These 
have  been  termed  bridle  or  pack-thread  strictures.  A  number  of  these 
bridles  may  exist,  the  orifices  of  which  may  or  may  not  correspond.  In 
some  cases  they  are  transverse  and  in  others  oblique  in  direction.  Their 
orifices  may  correspond  to  the  center  of  the  canal,  or  be  located  at  its 
side. 


ORGANIC    STRICTURE. 


185 


Occasionally  the  septum — or  band — has  a  crescentic  form,  involving 
only  a  part  of  the  canal.  The  precise  method  of  formation  of  these 
bridles  and  bands  is  not  known.  It  has  been  generally  accepted  that  in- 
flammatory lymph  is  never  thrown  out  upon  the  surface  of  the  mucous 
membrane.  This  is  difiicult  to  determine  positively,  however,  in  the  ab- 
sence of  abundant  post-mortem  evidence.  It  is  certainly  possible  where 
the  mucous  membrane  has  been  injured  by  instruments  or  chemic  irri- 
tants. It  has  been  claimed  that  in  some  cases  the  bridles  are  due  to  the 
fusing  together  of  the  natural  longitudinal  folds  of  the  urethra.  In  some 
instances  the  condition  results  from  a  tearing  up  of  valvular  flaps  of  mu- 
cous membrane  by  unskillful  instrumentation.  In  others  it  is  possible 
that  there  is  a  certain  amount  of  atrophy  of  submucous  connective  tissue 
and  mucous  follicles,  giving  rise  to  a  loose  flap  of  mucous  membrane. 


Fig.  53.— Bridle  stricture.     (After  Dittel. 


That  the  natural  folds  of  the  mucous  membrane  may  fuse  together,  so  to 
speak,  and  form  part  of  a  stricture-mass  the  author  firmly  believes  from 
conditions  found  in  certain  cases  of  perineal  section. 

Annular  stricture  may  be  due  to  thickening  of,  and  interstitial  deposit 
in,  the  mucous  membrane  or  to  submucous  inflammatory  infiltration.  The 
author  holds  that,  in  some  instances  of  apparent  annular  stricture  of  large 
caliber  observed  clinically,  the  condition  is  really  superficial  thickening  of 
the  mucous  membrane  in  the  form  of  congested  and  granular  plaques  at 
a  point  of  normal  relative  inelasticity  of  the  urethra.  This  lesion  need 
not  necessarily  involve  the  entire  circumference  of  the  canal,  although  it 
apparently  does  so  because  of  coincident  spasm.  Immediately  the  bulbous 
bougie  impinges  upon  such  a  sensitive  spot  the  urethra  contracts  down  in 
front  of  the  shoulder  of  the  instrument,   giving  the   same   sensation   as 


186 


STKICTUEE    OF    THE   UEETHEA. 


the  latter  is  withdrawn  as  that  imparted  by  decided  narrowing  of  the  canal. 
Obvionsly,  it  is  impossible^  even  with  the  endoscope,  to  determine  whether 
such  a  lesion  involves  the  entire  circumference  of  the  canal  or  only  a  cir- 
cumscribed patch. 

Tortuous  strictures  are  made  to  include  all  those  above  one-fourth  to 
one-half  inch  wide.  They  are  irregularly  contracted, — i.e.,  narrower  at 
some  points  than  at  others, — as  a  rule.  The  whole  pendulous  urethra  may 
be  involved,  always  in  varying  degree.  The  fact  that  extensive  tortuous 
stricture  is  narrower  at  some  points  than  others  is  explicable  upon  the 
same  grounds  as  the  localization  of  congested  and  granular  patches  and 


Fig.  54. — Annular  stricture.      (After  Dittel.) 


stricture  of  large  caliber  in  the  pendulous  urethra,  viz.:  the  existence  of 
normal  points  of  relative  inelasticity  where  the  inflammatory  process  is 
necessarily  severer  than  in  other  portions  of  the  canal.  As  already  remarked, 
the  formation  of  some  tortuous  strictures  may  perhaps  be  explained  by 
the  fusing  together  of  the  natural  folds  of  the  canal.  If  the  spiral  or 
rifled  form  of  the  urethra  in  a  flaccid  condition  be  admitted,  it  is  conceiv- 
able that  pronounced  infiltration  of  the  corpus  spongiosum  may  perma- 
nently fix  it  in  its  tortuous  conformation. 

The  number  of  strictures  varies.  It  has  been  most  generally  accepted 
that  stricture  is  usually  single,  but  careful  exploration  will  show,  in  the 
majority  of  cases,  more  than  one  stricture.    The  surgeon  who  believes  that 


i 


OEGAXIC    STEICTUEE. 


187 


a  urethra  which  will  admit  a  medium-sized  sound  is  necessarily  free  from 
stricture  is  apt  to  recognize  only  marked  cases  occurring  in  the  bulbo-mem- 
branous  region,  whereas  if  familiar  with  strictures  of  large  caliber  he  might 
discover  by  careful  exploration  in  a  given  case  several  strictures  in  the 
penile  portion  of  the  canal.  Dr.  Otis's  investigations,  while  perhaps  ex- 
aggerating the  frequency  and  multiplicity  of  strictures,  have  certainly 
shown  not  only  that  stricture  of  large  caliber  may  exist  where  the  urethra 


"d 


Fig.  55. — Tortuous  multiple  stricture,  a,  Annular  cicatricial  band,  ft,  &, 
Dilated  portions  of  urethra,  c,  Callous  periurethral  tissue  at  point  of 
deep  stricture,    d,  Sinuses  in  paraprostatica.     (After  Dittel.) 


will  admit  a  large  sound,  but  that  penile  stricture  is  much  more  frequent 
than  has  been  commonly  supposed.  Some  cases  of  so-called  multiple  strict- 
ure consist  of  irregular  contractions  of  a  long,  tortuous  stricture. 

The  amount  of  contraction  in  strictures  varies  greatly  between  those 
of  large  caliber,  in  which  there  is  but  superficial  thickening  and  loss  of 
elasticity  of  the  mucous  membrane,  and  those  severe  long-standing  strict- 


188 


STRICTUKE    OF    THE    UEETHKA. 


nres  in  which  the  lumen  of  the  urethra  is  so  contracted  as  to  resist  the 
introduction  of  a  fine  bristle,  even  when  the  stricture  is  exposed  post- 
mortem. The  contraction  is  very  rarely  sufficient  to  completely  prevent  the 
passage  of  urine.  It  has  been  asserted  that  in  this  sense  impermeable 
stricture  does  not  exist.  This,  however,  is  incorrect;  the  urethra  may  be 
so  injured  by  traumatism  that  the  resultant  stricture  completely  occludes 
its  lumen.  The  same  is  true  of  inflammatory  organic  stricture  complicated 
by  fistulas  that  divert  the  urine  from  its  normal  channel. 

The  rarity  of  strictures  impermeable  to  urine  is  easily  explained. 
Every  intelligent  practitioner  knows  how  difficult  it  is  to  heal  a  fistula  that 
communicates  with  secreting  structures  or  a  cavity  containing  materials 
that  escape  and  enter  the  lesion.     Urinary  fistula,  fistula  in   ano,   and 


Fig.  56. — Multiple  stricture,  penile  and  deep,  showing  varying  caliber. 
(After  Fessenden  Otis.) 


salivary  fistula  are  familiar  illustrations.  The  patency  of  urethral  stricture 
it  not  only  facilitated  by  the  passage  of  urine,  but  also  by  the  fact  that 
at  least  a  part  of  the  mucous  membrane  is  usually  intact.  The  inflam- 
matory deposit  occurs,  as  a  rule,  in  and  beneath  the  mucous  membrane,  and 
produces  obstruction  by  pressure  upon  it,  instead  of  by  fusing  opposing 
surfaces  of  the  urethral  walls.  Just  so  long  as  an  intact  strip  of  mucous 
membrane,  however  narrow,  exists  in  the  track  of  stricture  just  so  long 
is  it  permeable. 

Strictures  impermeable  to  instruments  are  also  rare,  particularly  in  the 
practice  of  surgeons  who  exhibit  sufficient  patience,  gentleness,  and  skill 
in  instrumentation.  A  stricture  should  not  be  pronounced  impermeable 
because  at  one,  or  perhaps  a  dozen,  attempts  it  is  found  impossible  to  pass 
an  instrument,  for  sooner  or  later,  especially  if  appropriate  general  measures 


OEGANIC    STKICTUEE.  189 

be  instituted,  an  instrument  will  usually  pass,  and,  no  matter  how  small  it 
may  be,  the  successful  passage  of  a  bougie  at  once  gives  the  surgeon 
control  of  the  case.  The  most  competent  andrologist  may  fail  to  pass 
a  stricture,  but  impermeability  of  the  stricture  at  one  end  of  the  bougie 
often  means  a  lack  of  tact  or  patience  at  the  other. 

Location  of  Steicture. — The  location  of  stricture  has  been  the  sub- 
ject of  much  controversy.  Dr.  Otis's  investigations  have  modified  in  certain 
quarters  the  prevalent  views  of  the  relative  frequency  of  stricture  at  differ- 
ent points  in  the  urethra.  That  the  opinions  of  Otis  have  not  been  allowed 
to  pass  unquestioned  goes  without  saying. 

Until  recently  the  dicta  of  Sir  Henry  Thompson  and  his  disciples  re- 
garding the  location  of  stricture  have  been  almost  universally  accepted. 
Thompson  found,  in  330  cases  of  stricture  examined  clinically,  213  at 
the  bulbo-membranous  Junction,  51  in  the  spongy  portion  of  the  canal — 
at  variable  points  between  one  inch  anterior  to  the  opening  in  the  triangular 
ligament  and  3  V2  inches  posterior  to  the  meatus — and  54  at  the  meatus, 
or  within  2  ^/o  inches  posterior  to  it.  In  370  cases  examined  post-mortem 
he  claimed  a  decided  preponderance  of  stricture  in  the  bulbo-membranous 
region,  i.e.,  the  space  between  a  point  1  inch  anterior  to  the  triangular  liga- 
ment and  another  ^/^  of  an  inch  posterior  to  it.  H.  Smith  examined  98 
preparations  of  stricture  in  the  London  Museums,  and  found  only  31  in 
the  membranous  urethra,  the  other  77  being  anterior  to  it.  The  majority 
of  the  latter  were  in  the  bulbous  urethra  or  just  anterior  to  it.  Otis  claims 
— the  author  thinks  justly — that  stricture  is  most  frequent  in  the  penile 
urethra.  It  is  obviously  impossible  for  surgeons  to  arrive  at  harmonious 
conclusions  so  long  as  standards  of  stricture  and  methods  of  exploration 
differ  so  widely.  Post-mortem  evidence  is  only  relatively  valuable.  The 
surgeon  who  reasons  from  clinical  experience  and  the  skillful  use  of  the 
urethrometer  and  bulbs  can  hardly  agree  with  Thompson,  and  must 
acknowledge  the  accuracy  of  Otis's  methods,  even  though  he  may  consider 
the  conclusions  of  the  latter  somewhat  overdrawn. 

In  the  author's  experience  stricture  appears  clinically  to  be  most  fre- 
quent at  the  meatus  or  just  within  it,  being  in  most  cases  congenital.  The 
next  most  frequent  site  is  the  junction  of  the  spongy  urethra  with  the  fossa 
navicularis,  or  just  posterior  to  it;  i.e.,  ^/ ^  to  1  '^J ^  inches  from  the  meatus. 
iSText  comes  the  bulbo-membranous  junction,  and  finally  a  point  about  1 
inch  anterior  to  it.  It  seems  to  occur  with  varying  frequency  in  the  inter- 
mediary portions  of  the  canal. 

As  Otis  remarks,  strictures  occur,  as  might  naturally  be  expected,  with 
greatest  frequency  Avhere  infiammation  begins  the  earliest  and  rages  the 
hottest,  the  frequency  gradually  diminishing  in  the  deeper  portions  of  the 
canal. 

From  a  clinical  stand-point  stricture  may  be  regarded  as  any  condition 
of  the  urethra  capable  of  producing  friction  by  obstructing  the  flow  of 


190  STRICTURE    OF    THE    URETHRA. 

urine,  to  however  slight  an  extent,  providing  said  obstruction  and  friction 
are  productive  of  pathologic  disturbances,  or,  if  the  latter  have  already 
begun,  tend  to  perpetuate  them.  A  point  of  normal  contraction  or  relative 
inelasticity  becomes  a  stricture  only  when  the  urethra  assumes  a  patho- 
logic state;  the  previously  normal  lack  of  distensibility  is  then  of  great 
pathologic  and  surgical  importance,  and  its  removal  may  be  imperatively 
necessary. 

Holding  that  any  point  of  contraction  or  inelasticity  in  the  urethra  in 
the  presence  of  a  pathologic  condition  of  the  mucous  membrane  consti- 
tutes a  stricture,  the  author  reiterates  the  conviction  that  stricture  is 
most  frequent  in  the  pendulous  portion.  If  care  be  taken  to  exclude  the 
element  of  deep  urethrismus, — which  is  not  always  so  easy  as  some  would 
have  us  believe, — ^the  proportion  appears  to  be  at  least  ten  to  one. 

That  there  is  great  variance  of  opinion  upon  this  point  is  well  known, 
and  as  Bumstead  and  Taylor  remarked  many  years  ago,  there  can  be  no 
harmony  of  results  between  those  who  study  the  subject  upon  the  living 
and  those  whose  estimates  are  formed  entirely  upon  observations  of  the 
cadaver.  In  1857  Folet  called  attention  to  the  frequency  of  fibrous  stricture 
in  the  pendulous  urethra,  and  its  comparative  rarity  in  the  bulbo-mem- 
branous  region.  This  author  claimed  that  deep  obstruction  existed  in  all 
cases  of  stricture  of  the  spongy  portion,  but  that  deep  stricture  was  nearly 
always  spasmodic  and  secondary  to  trouble  in  the  anterior  portion.  In 
1866  Verneuil  cooly  appropriated  Folet's  thunder,  and  expressed  essentially 
the  same  views,  almost  verbatim.  Otis,  writing  at  a  later  period,  while 
not  so  radical  as  his  French  predecessors,  promulgated  similar  views,  but  in 
a  much  more  comprehensive  and  thorough  manner.  His  demonstration 
of  the  relation  of  urethrismus  to  more  or  less  remote  reflex  irritation  was 
one  of  the  most  important  modern  contributions  to  genito-urinary  litera- 
ture, and  is  decidedly  complimentary  to  the  genius  of  American  surgery. 

In  estimating  the  frequency  of  deep  spasmodic  stricture  as  a  complica- 
tion of  obstruction  in  the  pendulous  urethra  an  important  source  of  fallacy 
should  be  remembered:  While  deep  stricture  may  apparently  be  demon- 
strated by  instrumentation  in  nearly  all,  if  not  all,  cases,  it  does  not 
necessarily  follow  that  deep  obstruction  exists  at  other  times.  The  tender 
urethra  resents  a  foreign  body  quite  as  vigorously  as  does  the  eye,  and  as 
soon  as  the  sound  touches  a  tender  spot  or  sensitive  stricture,  even  of  large 
caliber,  in  the  pendulous  urethra,  a  pronounced  reflex  contraction  is  ob- 
servable throughout  the  entire  canal:  this  is,  of  course,  most  pronounced 
in  the  deep  portion. 

In  some  cases,  as  already  stated  in  discussing  spasmodic  stricture,  deep 
spasm  exists  more  or  less  constantly;  but  in  many  of  these  there  is  actual 
organic  change  at  the  site  of  the  spasmodic  stricture;  this  may  be  true  or- 
ganic infiltration,  erosion,  or  a  congested  and  granular  patch.  Here  it  is 
often  very  difficult  to  determine,  even  approximately,  the  relative  propor- 


LOCALIZATION    OF    STKICTUEE.  191 

tions  of  spasm  and  organic  lesion.  The  true  condition  of  affairs  can  often- 
times only  be  determined  by  subtracting  the  sources  of  reflex  spasm  in  the 
anterior  urethra  by  urethrotomy. 

The  prostatic  portion  of  the  urethra  is  never  involved  in  inflammatory 
stricture,  so  far  as  known.  Thompson  says  on  this  point:  "I  may  confidently 
assert  that  there  is  not  a  single  case  of  stricture  of  the  prostatic  portion  of 
the  urethra  to  be  found  in  any  of  the  public  museums  of  London,  Edin- 
burgh, or  Paris." 

The  dicta  of  authorities  on  this  question  are  correct  only  as  regards 
acquired  stricture.  The  author  has  dissected  several  specimens  in  which 
congenital  narrowing  and  distortion  of  the  distal  portion  of  the  prostatic 
urethra  existed.  In  one  case  a  distinct  musculo-membranous  bridle  ex- 
tended across  the  prostatic  urethra. 

Pathologic  Localization  of  Stricture. — The  predilection  of  stricture 
for  different  portions  of  the  canal  has  not  been  clearly  explained.  The 
explanation  usually  given  for  the  relatively  greater  frequency  of  stricture 
in  various  portions  of  the  canal,  more  particularly  in  the  bulbo-membranous 
region,  is  that  there  is  in  these  situations  a  greater  amount  of  erectile 
tissue,  and  a  more  marked  tendency  to  localization  of  inflammatory  proc- 
esses, than  in  other  portions  of  the  canal. 

There  are  several  points  to  be  considered  in  attempting  to  explain  the 
occurrence  of  stricture  in  any  particular  location,  and  in  some  instances 
there  are  certain  special  elements  that  are  worthy  of  attention. 

Acquired  strictures  at  or  Just  within  the  meatus  are  favored  by  con- 
genital narrowing  at  this  point.  There*  is  constant  obstruction  to  the  uri- 
nary outflow,  and  the  resulting  friction  inevitably  enhances  inflammation. 
There  is  also  a  tendency  to  pocketing  of  secretions  in  the  fossa  navicularis, 
and  these  secretions — primarily  acrid  in  virulent  inflammation — soon  de- 
compose, aggravating  the  existing  inflammation.  The  nozzle  of  the  ordinary 
faulty  syringe  used  for  injecting  the  urethra  necessarily  produces  consider- 
able irritation  if  the  meatus  be  small.  The  frequency  of  acquired  stricture 
Just  within  the  meatus  is  thus  explained.  Long-nozzled  syringes  often  pro- 
duce stricture  some  little  distance  within  the  meatus  by  the  frequent  impact 
of  the  point  of  the  instrument  against  the  inflamed  mucous  membrane. 
At  such  an  area  of  irritation  the  inflammation  will  necessarily  become  local- 
ized and  chronic. 

The  relative  dilation  of  the  bulbous  urethra  and  fossa  navicularis 
favors  retention  of  urine  and  pathologic  discharges  at  these  points,  but  this 
is  not  very  important  in  the  causation  of  stricture  until  actual  obstruction 
by  inflammatory  thickening  of  the  mucous  membrane  occurs  Just  in  front 
of  the  dilated  point.  Under  ordinary  circumstances  these  expanded  por- 
tions of  the  urethra  are  flushed  out  from  time  to  time  by  the  urine.  When, 
however,  the  formation  of  stricture  begins,  a  small  quantity  of  decomposable 
fluid  will  inevitably  be  left  in  the  canal  at  these  points. 


193  STEICTUEE    OF    THE    UEETHEA. 

Traumatic  strictures  produced  during  instrumentation  necessarily  oc- 
cur at  the  site  of  injur}'.  The  principal  obstruction  to  instruments,  even 
in  the  normal  urethra,  being  at  the  opening  in  the  triangular  ligament, — i.e., 
the  bulbo-membranous  junction, — it  is  at  this  point  that  such  strictures 
are  most  often  found. 

Traumatic  strictures  from  falls  or  blows  upon  the  urethra  correspond 
to  the  site  of  injury.  It  is  very  difficult,  however,  to  catch  the  pendulous 
urethra  between  two  impinging  bodies  unless  done  with  deliberate  intent 
to  produce  injury.  In  the  case  of  the  deep  or  fixed  urethra,  however, 
injury  is  readily  produced  by  falls  or  blows  upon  the  perineum.  Stricture 
thus  produced  occurs  most  frequently  at  the  bulbo-membranous  junction, 
for,  as  already  noted,  this  point  corresponds  with  the  opening  in  that 
tense  fibrous  septum,  the  triangular  ligament,  and  also  with  the  sharp  lower 
border  of  the  subpubic  ligament.  This  latter  structure  is  of  semicartilag- 
inous  consistency,  its  edge  being  like  a  narrow  border  of  bone.  It  is  be- 
tween this  hard  tissue  and  the  impinging  body  that  the  urethra  is  usually 
caught  in  perineal  injuries,  and  slight  force  may  produce  sufficient  injury 
to  cause  traumatic  stricture.  Comparatively  slight  force  may  sever  the 
urethra  completely.  Injuries  that  are  practically  unnoticed  in  early  life 
may  produce  organic  stricture  later  on.  These  traumatic  strictures  are,  on 
the  average,  the  worst  with  which  we  have  to  deal. 

The  location  of  stricture  due  to  the  introduction  of  strong  chemicals 
into  the  urethra  may  be  determined  by  the  same  normal  anatomic  con- 
ditions as  in  ordinary  virulent  urethritis.  They  may,  on  the  other  hand, 
occur  at  the  point  chiefly  affected  by  the  caustic  or  chemic  substance. 

Foreign  bodies  in  the  urethra  may  produce  localized  inflammation  and 
perhaps  ulceration  that  determines  the  site  of  future  stricture.  Foreign 
bodies  are  most  likely  to  lodge  in  one  of  the  dilated  portions  of  the  canal. 
Under  such  circumstances  the  foreign  material  produces  pressure  and  irrita- 
tion chiefly  at  that  point  in  the  mucous  membrane  where  its  outward 
passage  with  the  flow  of  urine  is  obstructed. 

Injury  incidental  to  chordee  is.  often  responsible  for  the  localization 
of  stricture.  This  condition  interferes  with  the  normal  distensibility  and 
elasticity  of  the  urethra,  and  during  erection  produces  a  strain  upon  the^ 
tissues  of  the  corpus  spongiosum  and  the  urethra  at  some  particular  point 
or  points.  The  point  of  greatest  convexity  of  the  curve  produced  by  the 
chordee  is,  as  a  rule,  where  the  greatest  strain  is  experienced.  The  irrita- 
tion produced  by  this  straining  of  tissue  is  apt  to  induce  the  localization  of 
stricture  at  this  point.  In  some  instances  the  corpus  spongiosum  or  mucous 
membrane  of  the  urethra  yields  to  the  tension  and  is  lacerated  to  a  greater 
or  less  degree.  This  may  be  produced  by  the  patient's  forcibly  bending 
the  penis  in  the  fatuous  notion  that  rupture  of  the  chordee  cures  gonor- 
rhea. The  author  believes,  however,  that  in  marked  cases  it  may  result 
from  frequent  and  vigorous  erections,  the  laceration  being  unrecognized, 


LOCALIZATION    OF    STEICTUEE.  193 

save  perhaps  where  the  patient  calls  the  attention  of  the  surgeon  to  the 
fact  that  there  has  been  more  or  less  hemorrhage  during  the  night  as  a 
result  of  the  chordee.  This  is  a  frequent  cause  of  stricture,  the  subsequent 
stricture  occurring  at  the  site  of  injury.  Whenever  an  appreciable  quantity 
of  blood  appears  in  gonorrheal  discharge  such  minute  traumatisms  may  be 
inferred.  These  slight  injuries  often  form  the  groundwork  for  future 
stricture-building. 

Certain  normal  anatomic  peculiarities  of  the  structure  of  the  canal 
are  the  most  important  elements  in  the  determination  of  stricture  at  special 
points  in  the  urethra.  These  are  the  chief  bones  of  contention  among  the 
warring  factions  whose  causus  lelli  is  the  question:  To  cut  or  not  to  cut?  It 
has  been  shown  by  Weir,  Sands,  and  others  that  certain  points  of  narrow- 
ing exist  in  the  spongy  urethra,  termed  by  them  normal  contractions,  being 
distinct  from  the  normal  narrow  points  usually  recognized — i.e.,  the  meatus, 
bulbo-membranous  junction,  and  the  point  of  union  of  the  spongy  urethra 
with  the  fossa  navicularis.  This  description  appears  to  the  author  some- 
what misleading.  The  urethra  is  an  elastic  tube  susceptible  of  considerable 
dilation.  Its  elasticity,  however,  is  not  uniform  throughout,  but  as  a  con- 
sequence of  sparsity  of  elastic  tissue,  with  a  preponderance  of  connective 
and  fibrous  tissue  in  the  erectile  structure  of  the  corpus  spongiosum  and 
deficiency  of  areolar  tissue  beneath  the  mucous  membrane,  there  are  various 
points  of  relative  inelasticity  and  limited  dilatability.  In  certain  portions 
of  the  canal  relative  inelasticity  and  limited  dilatability  are  due  to  anatomic 
peculiarities  of  the  surrounding  structures.  For  example,  at  the  opening  in 
the  triangular  ligament  the  urethra  is  not  only  narrow,  but  surrounded  by 
dense  and  unyielding  tissues.  The  meatus  is  comparatively  inelastic  in 
most  individuals,  even  when  it  cannot  be  said  to  be  congenitally  contracted. 
The  corpus  spongiosum  is  a  little  thicker  at  the  junction  of  the  fossa  navic- 
ularis with  the  spongy  urethra  and  at  the  junction  of  the  latter  with  the 
bulb  than  elsewhere.  At  these  various  points,  moreover,  the  areolar  tissue 
beneath  the  mucous  membrane  is  disproportionately  scanty  and  the  latter 
is  more  closely  applied  to  the  tissues  which  it  invests.  It  would  seem  also 
that,  as  there  is  more  strain  at  these  points  than  in  other  portions  of  the 
canal,  the  urethra  is  normally  reinforced  at  these  points  by  increased  density 
of  fibro-connective  tissue. 

In  explaining  the  localization  of  stricture  we  will  take  as  our  point  of 
departure  the  fact  that  the  urethra  is  a  dilatable  tube,  the  elasticity  of  which 
varies  at  different  points  in  the  canal.  Through  this  tube  water  at  a  certain 
pressure  and  in  a  certain  volume  is  forced  at  more  or  less  frequent  intervals. 
Obviously,  the  greatest  friction  is  produced  at  the  various  points  of  normal 
contraction  and  relative  inelasticity.  Against  the  strain  and  friction  pro- 
duced at  these  points  Nature  has  provided  a  certain  amount  of  reinforce- 
ment of  tissue,  and  under  normal  circumstances,  with  a  healthy  mucous 
membrane,  the  pressure  and  friction  do  not  produce  injury.     When,  how- 


194  STRICTURE    OF    THE    URETHRA. 

ever,  the  canal  is  inflamed,  as  in  acnte  nrethritis,  its  Innien  and  elasticity- 
are  decreased.     Urine  is  neyertlieless  pumped  tlirongh  the  tube  in  as  great 
volume  and  as  often  as  under  normal  circumstances,  producing  by  its  press- 
ure and  friction  and  chemic  effects  considerable  irritation,  as  evidenced  by 
pain  and  smarting.     Obviously,  the  greatest  amount  of  irritation  occurs  at 
the  points  of  relative  inelasticity,  and  consequently  it  is  here  that  inflam- 
mation tends  to  localize  itself,  and  persists  long  after  the  remainder  of  the 
mucous  membrane  has  returned  to  an  approximately  normal   condition. 
This   continual  friction  and  irritation  is  interpreted  by  the   controlling  1 
centers  and  nervous  supply  of  the  part  as  a  demand  for  reparative  material;] 
hence  there  must  inevitably  be  more  or  less  plastic  exudate  at  these  points. 
This  exudate  is  Nature's  bulwark  against  strain  and  irritation  and  aims  toi 
secure  physiologic  rest.    Unfortunately,  however,  this  conservative  process 
is  here  misapplied,  for  if  complete  absorption  does  not  occur,  the  exuded 
inflammatory   material    remains,    organizes,    contracts,    and    constitutes    a| 
stricture. 

The  existence  of  points  of  relative  inelasticity  probably  also  explains 
abraded,  congested,  and  granular  patches  of  the  mucous  membrane  in  cases 
that  are  not  due  to  frequent  contact  of  instruments.  The  relatively  greater 
amount  of  friction  at  such  points  tends  to  produce  abrasion  of  the  mucous 
membrane  and  removal  of  epithelium,  more  frequently  than  at  other  points. 
Eapid  removal  and  reformation  of  cells  results  in  impaired  vitality  and  a 
vicious  habit  of  cell-formation.  This  is  one  of  the  most  important  factors 
in  chronic  urethritis. 

The  physiologic  and  biologic  elements  in  the  localization  of  stricture 
must  not  be  forgotten:  the  vicious  habit  of  cell-formation  already  referred 
to  is  of  great  importance.  In  the  course  of  acute  urethritis  there  is  a  tend- 
ency to  rapid  formation  of  epithelium  of  a  low  grade.  This  is  a  reparative, 
a  conservative,  process,  but,  unfortunately,  a  certain  biologic  law  comes 
into  play  here,  viz.:  in  inverse  proportion  to  the  degree  of  differentiation 
of  cells  is  their  rapidity  of  proliferation  and  their  tendency  to  degeneration. 
Tile  consequence  of  this  law  is  an  erosion  at  the  point  of  friction,  and, 
secondarily,  a  plastic  deposit  to  resist  strain.  Comment  upon  this  is  un- 
necessary; the  subsequent  metamorphosis  of  this  deposit  into  fibrocon- 
nective  tissue  is  well  known.  In  the  pendulous  urethra  especially — and 
probably  also  in  the  fixed  portion — the  plastic  deposit  may  absorb,  but  the 
friction  remains  and  a  gleet  is  often  kept  up.  The  points  of  normal  con- 
traction and  relative  inelasticity  have  now  become  of  pathologic  importance. 

It  would  seem  to  be  immaterial  whether  these  points  were  primarily 
present  in  the  canal  as  normal  conditions  or  not,  as  regards  their  surgical 
relations.  The  question  is  not  whether  they  are  adventitious,  as  claimed  by 
Otis,  or  normal  as  claimed  by  Weir  and  Sands,  but  "What  relation  do  they 
bear  to  the  abnormal  state  of  the  canal?"  The  difference  between  the  two 
conditions  is  one  of  degree,  not  kind. 


MORBID    ANATOMY    OF    STRICTURE.  195 

From  what  has  been  said,  the  direct  relation  of  stricture  to  the  severity 
of  the  primary  urethritis  may  be  clearly  seen. 

It  is  a  self-evident  proposition  that  if  what  has  been  said  regarding  the 
relation  of  stricture  to  friction  be  true,  the  same  holds  good  with  relation 
to  granular,  congested,  and  eroded  patches  in  the  canal.  Within  certain 
limits  the  indications  for  treatment  may  be  the  same.  In  addition  to  the 
element  of  friction  in  producing  stricture  and  other  lesions  of  the  urethra, 
a  varying  degree  of  importance  of  retained  infectious  and  inflammatory 
products  at  points  of  narrowing  is  acknowledged. 

Eegarding  the  importance  of  urethral  friction,  Otis  says: — 

It  is  only  necessary  to  establish  the  fact  that  the  normal  resiliency  of  the 
urethra  is  diminished,  at  a  given  point  to  prove  that  during  micturition  a  perturba- 
tion of  the  stream  must  occur  at  such  pointy  even  if  it  is  not  sufficient  to  attract 
attention  in  any  way.  Hence  the  slightest  contractions  assume  an  importance  which 
could  not  be  inferred  from  the  apparent  freedom  from  trouble  in  passing  the  urine. 
They  establish  a  localized  point  of  friction,  and  of  necessity  an  increased  excitement 
in  the  vessels  of  the  part,  possibly  only  enough  to  disturb  the  complete  elaboration 
of  epithelial  material  and  to  cause  a  shreddy  deposit  to  take  the  place  of  the  clear 
normal  secretion;  and  this  may  occur  with  very  slight  or  without  the  least  abnormal 
sensation  being  present.  The  presence  of  the  mucoid  shreds  in  the  urine  may  be 
the  only  evidence  of  commencing  trouble.  But  a  permanent  point  of  friction  once 
established,  greater  than  the  natural  conservative  power  of  the  surrounding  parts  is 
able  to  counterbalance,  obstruction  is  increased  by  the  natural  aggregation  of  plastic 
material  at  the  point  of  irritation.  In  this  way  the  tendency  to  recovery  is  com- 
bated and  a  permanent  point  of  inflammatory  action  is  established. 

Thus  the  difficulty,  which  commenced  simply  as  an  obstruction  to  the  resiliency 
of  the  urethral  walls,  progresses  certainly  and  naturally  to  the  point  of  narrowing, 
to  a  greater  or  less  degree,  the  caliber  of  the  urethral  canal. 

When  the  views  of  Dr.  Otis  first  appeared  they  gave  rise  to  much  opposi- 
tion. Among  those  who  vigorously  combated  the  teachings  of  Otis  was 
the  author's  lamented  friend,  the  late  Henry  B.  Sands.  Among  other 
arguments,  Dr.  Sands  presented  some  carefully  prepared  casts  of  the  infer- 
entially  normal  urethra  that  showed  great  variation  of  caliber.  What  struck 
the  author  as  most  peculiar  was  the  controversy  as  to  the  normal  or  ab- 
normal character  of  many  of  the  penile  strictures  diagnosed  by  Otis.  Taking 
into  consideration  the  purely  mechanic  effects  of  stricture  of  the  urethra, 
it  is  difficult  to  understand  how"  quibbling  was  possible.  What  difference 
in  results  and  in  treatment  could  be  maintained  between  a  gleet  perpetuated 
by  normal  points  of  friction  in  the  urethra  and  a  gleet  perpetuated  by  ac- 
quired stricture?  Sooner  or  later,  true  adventitious  deposit  occurs  and  the 
point  of  normal  relative  indistensibility  merges  into  an  acquired  neoplastic 
contraction.  Points  of  relative  inelasticity  or  contraction  and  points  of  ac- 
quired contraction  may  be  precisely  the  same  from  a  clinical  stand-point  in 
the  presence  of  a  pathologic  condition  of  the  mucous  membrane.  The  cure 
of  the  case  demands  their  removal  independently  of  their  origin. 

Morbid  Ajf atomy.  —  When  inflammation  becomes  localized  at  any 


196 


STEICTUEE    OF    THE   UEETHEA. 


point  in  the  urethra  an  extension  of  the  process  to  the  snbinucous  tissue 
results,  or  there  is  an  increase  of  pre-existing  periurethral  inflammatory 
thickening.     This  consists  of  a  submucous  infiltration  of  embryonal  cells 


Fiff.  57. — Casts  of  alleged  normal  urethras,  showing  points  of  contraction, 
1,  2,  3,  4,  5,  6.     (After  Sands.) 

that  soon  forms  a  more  or  less  dense  zone  of  periurethral  sclerosis.  It  may 
or  may  not,  at  the  beginning,  form  a  distinct  thickening  of  the  corpus 
spongiosum.  This  process  constitutes  the  dehut  of  stricture,  and  is  the  con- 
dition most  frequently  detected  in  chronic  urethritis  by  the  bulbs  or  ure- 


MORBID    ANATOMY    OF    STRICTUEE.  197 

thrometer.  Obviously  it  is  upon  the  loss  of  elasticity  at  the  affected  point 
that  the  detection  of  the  lesion  depends.  The  same  loss  of  elasticity  explains 
the  symptoms  of  stricture  and  its  tendency  to  growth. 

In  some  instances  there  is  slight  thickening  of  the  mucosa^  with  little 
or  no  submucous  proliferation  of  connective  tissue,  the  epithelium  being 
more  or  less  denuded  and  covered  with  muco-purulent  secretion.  The  fol- 
licles of  the  urethra  at  this  point  are  dilated,  thickened,  and  disposed  to 
hypersecretion.  When  the  process  is  a  little  farther  advanced  the  mucous 
membrane  is  thickened,  congested,  perhaps  covered  with  fungous  granula- 
tions, with  more  or  less  infiltration  and  thickening  of  the  submucous  con- 
nective tissue  and  corpus  spongiosum.  In  more  advanced  cases  the  corpus 
spongiosum  is  extensively  infiltrated  and  of  semicartilaginous  consistency, 
often  so  dense  that  erection  is  imperfect.  This  condition  is  really  chronic 
interstitial  inflammation  of  the  corpus  spongiosum,  acting  precisely  like 
^cute  inflammation  in  the  production  of  chordee.  Bridles,  bands  or  flaps 
of  thickened  mucous  membrane,  may  be  present. 

The  degree  of  occlusion  of  the  urethral  lumen  is  variable.  In  some 
strictures  of  large  caliber  superficial  infiltration  and  thickening  of  the 
mucous  membrane  are  localized  in  a  very  small  area, — perhaps  not  involv- 
ing the  entire  circumference  of  the  canal — its  lumen  being  contracted  but 
little,  if  any.    In  the  severe  forms  occlusion  may  be  almost  complete. 

The  secondary  results  of  stricture  are  chiefly  incidental  to  urinary  ob- 
struction, varying  greatly  in  degree.  In  extreme  instances  all  the  condi- 
tions possible  to  urinary  obstruction  and  chronic  inflammation  of  the 
urinary  way  have  been  found  post-mortem. 

The  urethra  anterior  to  organic  stricture  may  be  somewhat  contracted 
from  chronic  inflammation  of  the  mucous  membrane  associated  with  com- 
parative disuse.  The  stream  of  urine  passing  through  the  stricture  not 
being  large  enough  to  fully  dilate  the  urethra  anteriorly,  contraction 
naturally  results.  The  urethra  anterior  to  a  stricture  has  been  said  to  be, 
in  rare  cases,  dilated.  It  is  difficult  to  understand,  however,  how  this  could 
occur,  unless  from  extensive  atrophy  of  submucous  follicles  and  connective 
tissue. 

Urinary  obstruction  necessarily  first  afEects  the  urethra  behind  the 
stricture.  At  this  point  the  canal  becomes  more  or  less  dilated,  perhaps 
thinned.  As  a  consequence  of  interference  with  the  wave  of  contraction 
of  the  accelerator-urince  and  compressor-urethrcB  muscles  produced  by  the 
stricture,  in  combination  with  urethral  dilation  behind  it,  this  part  of  the 
canal  is  never  free  from  urine,  a  drop  or  so  invariably  remaining  after 
micturition.  This  residual  urine  decomposes  and  enhances  the  chronic  in- 
flammation. The  inflammation  is  also  aggravated  by  the  friction  of  the 
urine,  and  in  extreme  cases  by  straining  efforts  in  voiding  it.  As  a  product 
of  the  inflammation  a  pasty,  muco-purulent  secretion  will  be  found  at  this 
point.    This  constitutes  the  discharge  in  most  cases  of  gleet  due  to  stricture. 


198 


STEICTUKE    OF   THE   UEETHRA. 


As  the  urine  flows  over  the  diseased  part  the  secretion^  in  combination  with 
desquamated  epithelium,  is  rolled  up  in  little  thready  filaments  {tripper- 
fdden)  that  may  he  seen  floating  about  in  the  voided  fluid.  There  may  be 
considerable  congestion  of  the  mucous  membrane;  so  that  the  secretion 
is  sometimes  mixed  with  a  certain  quantity  of  blood.  In  the  author's  ex- 
perience this  is  especially  likely  to  occur  in  syphilitics. 

Consequent  upon  urinary  decomposition  a  deposition  of  more  or  less 
earthy  material,  possibly  a  small  calculus,  may  be  found  behind  a  tight 
stricture  of  long  standing.  Eenal  or  vesical  calculi  may  become  lodged  at 
this  point.  In  a  recent  perineal  section  the  author  found  a  calculus  as  large 
as  a  marrowfat-pea  behind  a  tortuous  stricture.  In  another  case  which  he 
operated  upon  Dr.  Buell  S.  Sogers,  of  Chicago,  found  eight  small  calculi. 


Fig.  58. — Dilation  and  trabeeulation  of  prostatic  urethra,  secondary  to 
close  bulbo-membranous  stricture. 


As  the  case  advances  the  mucous  membrane  behind  the  obstruction 
becomes  thin  and  fragile,  and  perhaps  ulcerated;  sometimes,  as  a  conse- 
quence of  a  straining  efi'ort  during  micturition,  a  slight  rupture  occurs,  a 
drop  or  two  of  germ-laden  urine  escaping  into  the  periurethral  cellular  tis- 
sue. Abscess  with  inevitable  fistula — or  possibly  burrowing  and  a  number 
of  fistulas — and  infiltration  of  urine,  with  resultant  sloughing  and  death, 
may  occur.  Wherever  such  septic  fluid  comes  in  contact  with  cellular  tis- 
sue it  inevitably  destroys  its  vitality.  Its  destructive  efi'ects  upon  cellular 
tissue  resemble  those  of  erysipelatous  infection;  it  produces,  in  short,  septic 
cellulitis. 

The  various  glands  that  open  into  the  urethra  posterior  to  organic 
stricture  are  affected  to  a  greater  or  less  extent  in  marked  cases  by  the 


MOEBID    ANATOMY    OF    STKICTUEE.  199 

lu'inary  obstruction  and  mucous  inflammation.  The  urethral  follicles,,  pro- 
static glands^  and  Cowper's  ducts  become  dilated,  thickened',  and  inflamed  as 
a  consequence  of  frequent  infection,  combined  with  straining  in  micturition. 
Even  anterior  to  the  stricture  the  sinuses  and  follicles  will  be  found  to 
]je  dilated — often  sufficiently  to  obstruct  the  passage  of  fine  instruments. 
This  dilation  is  due  to  successive  distension  with  and  evacuation  of  in- 
flammatory products.  The  prostate  becomes  more  or  less  congested  from 
the  frequent  bruising  incidental  to  spasmodic  and  difficult  urination.  It 
is  possible  that  this  condition  is  one  of  the  causes  of  enlarged  prostate  in 
advanced  life. 

The  bladder  is  always  more  or  less  involved,  even  in  stricture  of  mod- 
erate degree.  As  a  result  of  continual  obstruction  to  urination,  the  detrusor- 
urince  muscle  becomes  hypertrophied.  As  obstruction  increases,  the  viscus 
may  rarely  become  dilated,  portions  of  its  walls,  where  the  bundles  of  mus- 
cular fibers  are  deficient,  becoming  dilated  and  thinned,  thereby  producing 
sacculi.  In  these  sacculi  urine  collects  and  decomposes,  possibly  forming 
calculi.  Barely,  the  bladder,  instead  of  being  dilated,  is  enormously  thick- 
ened from  interstitial  cystitis,  ^nd  contracted  so  that  it  holds  but  a  very 
small  quantity  of  urine.  iSTeither  dilation  nor  contraction  are  so  marked 
nor  so  frequent  as  in  prostatic  hypertrophy. 

The  mucous  membrane  is  the  seat  of  chronic  inflammation  and  pre- 
sents a  characteristic  dusky  or  slaty  hue.  It  is  covered  by  muco-purulent 
secretion,  perhaps  mingled  with  sabulous  material,  and  is  usually  greatly 
thickened,  perhaps  rugose.  Calculi  may  form  in  the  bottom  of  the  blad-  ■ 
der  in  the  same  manner  as  under  other  circumstances  involving  urinary 
obstruction. 

Inflammation  and  dilation  of  the  ureters  and  pelves  of  the  kidneys 
occur  sooner  or  later  in  extreme  cases.  Pyelitis,  with  or  without  the  forma- 
tion of  calculi,  develops  under  such  circumstances.  Kephric  or  perinephric 
abscesses  may  occur.  The  secreting  structure  of  the  kidneys  undergoes 
those  characteristic  changes  that  have  been  described  under  the  omnibus 
term  of  "surgical  kidney." 

One  of  the  conditions  observed  in  the  so-called  surgical  kidney  is 
interstitial  proliferation  of  connective  tissue  and  deficiency  of  normal 
stromal  elements.  Nature  is  very  prodigal  in  her  supply  of  reparative 
material  to  relieve  strain,  prevent  irritation,  or  repair  breaches  of  tissue. 
Obstruction  to  the  urinary  outflow  results  in  the  accumulation  of  a  physio- 
logic army  of  proliferating  cells  sent  to  the  renal  tissue  or  developed  in  loco 
for  the  purpose  of  resisting  strain — which  strain  is  interpreted  by  the 
trophic  centers  as  a  threatened  breach  of  tissue.  Unfortunately,  this  tissue 
reinforcement  develops  no  qualities  of  elasticity  as  it  organizes,  but  as  the 
strain  goes  on  yields  before  the  pressure  and  enhances  the  passive  dila- 
tion. Moreover,  it  not  only  absorbs  almost  as  rapidly  as  it  is  formed, — 
after  a  certain  point  has  been  reached, — but  it  displaces,  strangulates,  and 


200  STEICTUEE    OF    THE    URETHRA. 

produces  absorption  of  the  normal  secreting  elements  of  the  renal  structure. 
In  some  of  the  more  marked  forms  of  surgical  kidney  associated  with 
pyelitis,  pyelonephritis,  or  pyonephrosis  we  find  disseminated  suppurative 
foci  in  the  secretory  structure,- — i.e.,  the  cortex  of  the  kidney.  These  foci 
may  form  in  two  ways:  by  direct  infection — i.e.,  contiguity  of  tissue — or 
indirect  infection  by  pyemic  infarcts.  Whether  this  be  due  to  toxins  or 
to  germs,  per  se,  is  not  pertinent  here. 


Fig.  59.- — Showing  extreme  dilation  of  proximal  side  of  genito-urinary  tract 
in  stricture  of  long  standing.     (After  Morris.) 

In  fatal  cases  of  uremia  following  operations  for  stricture  the  secreting 
structure  is  usually  intensely  congested  and  swollen  from  reflex  hyperemia, 
produced  by  the  shock  of  the  operation  or  the  anesthetic. 

It  is  to  be  remembered  that  these  various  consequences  of  stricture 
are  not  due  to  any  specific  quality  of  the  lesion,  but  are  the  typic  results 
of  extreme  and  prolonged  obstructive  disease  of  the  genito-urinary  tract. 


ETIOLOGY    OF    OEGAKIC    STEICTUKE.  201 

The  description  given  of  surgical  kidney,  for  example,  fits  all  cases  of  renal 
disease  secondary  to  obstruction  of  the  urinary  way,  however  produced. 
So  far  as  stricture  is  concerned,  the  possible  pathologic  results  are  numer- 
ous and  severe  enough  to  convince  the  most  skeptic  that  through  the 
medium  of  stricture  gonorrhea  is,  indeed,  a  serious  disease.  The  results  of 
stricture  and  the  operations  it  necessitates  are  often  directly  fatal  to  life. 
This  makes  gonorrhea  much  more  dangerous  than  syphilis. 

The  density  of  stricture  necessarily  varies  considerably  according  to  its 
origin  and  duration,  the  habits  of  the  patient,  and  the  degree  of  irritation 
present.  In  old  and  severe  cases  it  may  be  almost  cartilaginous  in  con- 
sistency. Strictures  of  traumatic  and  chemic  origin  are  very  hard,  because 
a  greater  or  less  amount  of  normal  tissue  has  been  destroyed  and  superseded 
by  true  cicatricial  tissue. 

Etiology. — The  most  frequent  cause  of  stricture  is  urethritis.  It  has 
been  said  that  it  is  the  duration  rather  than  the  severity  of  the  inflamma- 
tion AA'hich  determines  the  occurrence  of  stricture, — i.e.,  that  a  long-con- 
tinued inflammation  of  low  grade  is  the  most  usual  cause.  This,  however, 
is  open  to  question,  for,  while  stricture  is  usually  associated  with  chronic 
urethritis,  it  must  be  remembered  that  in  the  majority  of  cases  the  symptoms 
of  chronic  inflammation  are  dependent  upon  the  stricture,  and  the  stricture 
itself  upon  antecedent  virulent  inflammation;  in  brief,  the  stricture  causes 
a  perpetuation  of  the  inflammation,  and  not  the  reverse. 

It  may  be  safely  assumed  that  the  danger  of  subsequent  stricture  and 
of  chronicity  of  urethritis  is  directly  proportionate  to  the  severity  of  the 
acute  inflammatory  process.  Eepeated  attacks  of  inflammation  almost  in- 
evitably lead  sooner  or  later  to  organic  stricture.  It  is  rather  exceptional — 
if,  indeed,  it  ever  occurs — that  the  urethra  assumes  its  normal  condition 
throughout  its  entire  extent,  for  a  prolonged  period  after  virulent  ure- 
thritis. There  exists  in  most  instances  a  greater  or  less  number  of  more 
or  less  damaged  spots  in  the  mucous  membrane,  which,  sooner  or  later,  are 
likely  to  form  a  foundation  for  stricture.  They  will  inevitably  do  so  if  the 
patient  has  a  succession  of  attacks  of  gonorrhea. 

Stricture  may  result  from  traumatism  produced  by  instruments  within 
the  canal  or  injury  from  without.  Severe  injuries  to  the  perineum  usually 
involve  the  urethra,  and  are  inevitably  followed,  as  already  indicated,  by 
the  worst  form  of  organic  stricture.  When  the  urethra  is  entirely  cut 
across  or  severely  bruised  the  loss  of  tissue  is  replaced,  as  in  other  situa- 
tions, by  cicatricial  deposit.  This  is  disproportionately  dense,  because  of 
the  lack  of  rest  incidental  to  urination  and  sexual  excitement.  The  con- 
traction of  this  tissue  constitutes  the  stricture.  Injuries  that  were  ap- 
parently trivial  at  the  time,  and  have  perhaps  been  long  since  forgotten, 
are  often  the  source  of  stricture.  It  takes  but  little  force  to  injure  the  deep 
urethra,  and  an  accident  that  has  apparently  produced  little  or  no  injury 
is  liable  to  produce  stricture  later  on. 


303  STEICTUEE    OF    THE    UEETHKA. 

Injury  to  the  perineal  urethra  may  result  from  kicks,  blows,  and  falls 
astride  such  objects  as  a  wall  or  a  fence.  The  author  has  seen  a  case  oc- 
curring in  an  athlete  as  a  consequence  of  falling  astride  a  horizontal  bar. 
Fracture  of  the  pelvic  bones  and  gunshot  and  stab  wounds  have  been  known 
to  produce  traumatic  stricture. 

Eupture  of  chordee  often  superadds  traumatism  to  the  usual  inflam- 
matory causes  of  stricture.  Careless  instrumentation  is  sometimes  responsi- 
ble for  stricture.  It  is  very  easy  to  force  a  catheter  or  sound  through  the 
urethral  walls  or  produce  sufficient  injury  by  bruising  and  laceration  to 
result  in  cicatricial  deposit  and  stricture. 

Cicatrices  from  chancre  and  chancroid  occurring  at  the  meatus  or 
within  the  urethra  inevitably  produce  stricture.  Urethral  injections  are 
popularly  supposed  to  be  responsible  for  a  large  proportion  of  cases  of 
stricture,  and  this,  it  must  be  confessed,  has  some  foundation  in  fact;  for 
some  surgeons,  in  their  enthusiasm  and  desire  for  a  speedy  cure  of  their 
cases,  are  apt  to  forget  that  the  urethra  is  lined  by  a  very  delicate  mucous 
membrane,  which  is  normally  extremely  sensitive  to  irritants,  and  is  cer- 
tainly more  than  ordinarily  sensitive  when  inflamed.  Mild  injections  given 
in  a  proper  manner  and  at  the  proper  period  will  not  produce  stricture,  but, 
on  the  contrar}',  tend  to  prevent  it  by  their  beneficial  effect  upon  the  in- 
flamed membrane.  The  prejudice  existing  in  the  minds  of  the  laity  re- 
garding injections  is  to  be  deplored,  as  they  are  often  very  useful.  Although 
the  surgeon  may  sometimes  be  responsible  for  the  occurrence  of  stricture, 
it  is  safe  to  say  that  in  the  majority  of  instances  the  disease  is  due  to  ag- 
gravation of  the  inflammation  by  lack  of  rest,  sexual  indulgence  or  excite- 
ment, intemperance,  and  self-treatment.  The  counter-prescribing  in  vogue 
among  a  certain  class  of  druggists  is  often  responsible  for  stricture.  This 
is  a  matter  that  physicians  would  do  well  to  take  under  advisement.  There 
is  no  disease  with  which  the  counter-prescriber  takes  so  many  liberties  as 
with  gonorrhea.     The  results  are  oftentimes  very  disastrous. 

Independently  of  the  strength  of  injections,  it  is  to  be  remembered 
that  even  simple  water  may  cause  mechanic  injury  when  urethritis  is  very 
acute. 

It  is  probable  that  individual  peculiarities  are  sometimes  predisposing 
causes  of  stricture.  Thompson  believes  that  heredity  is  a  factor  in  its 
formation  in  some  instances. 

The  theory  that  the  members  of  certain  families  show  a  special  tend- 
ency to  connective-tissue  formation  and  flbrous  thickenings  in  various  situa- 
tions from  chronic  inflammation  is  plausible  enough,  yet  it  would  be  diffi- 
cult, in  the  majority  of  cases,  to  trace  the  relation  of  heredity  to  stricture. 
Cachexias  of  various  kinds  sometimes  constitute  predisposing  causes  of 
stricture  by  perpetuating  and  enhancing  the  severity  of  inflammation  in  any 
situation.  It  has  occurred  to  the  author  that  persons  with  syphilis  are  espe- 
cially predisposed  to  stricture,  seemingly  because  localized  proliferation  of 


SYMPTOMS    OF    OEGAXIC    STRICTURE.  203 

sypliilized  cells  is  likely  to  occur  at  any  point  of  local  irritation  developing 
during  active  syphilis.  This  is  a  practical  point,  as  it  is  obvious  that  spe- 
cific internal  medication  may  sometimes  be  a  useful  adjunct  to  surgical  meas- 
ures. The  same  considerations  apply  especially  to  the  gouty  and  rheumatic 
diatheses  as  regards  a  tendency  to  fibrous  thickenings.  Any  condition 
favoring  hyperacidity  of  the  urine  predisposes  to  stricture.  Habitual  drink- 
ers are  more  liable  to  stricture  than  abstainers.  The  ingestion  of  alcohol 
makes  the  tissues  in  general  irritable  and  susceptible  to  inflammation. 

Symptoms. — One  of  the  earliest  symptoms  of  stricture  is  disturbed 
micturition.  The  decomposition  of  the  small  quantity  of  residual  urine 
remaining  behind  the  urethral  obstruction  gives  rise  to  toxins  that  are 
very  irritating  to  the  mucous  membrane,  as  shown  by  the  chronic  inflam- 
mation— sometimes  ulceration — found  at  this  point.  This  causes  reflex  or 
direct  irritation  of  the  vesical  neck, — i.e.,  the  deep  urethra, — with  conse- 
quent frequent  desire  to  urinate.  Some  patients  first  consult  the  surgeon 
regarding  frequent  micturition,  possibly  occurring  only  at  night.  Under 
normal  circumstances  the  bladder  tolerates  its  contents  during  the  hours  of 
sleep,  but  in  the  presence  of  irritating  affections  of  the  genito-urinary  tract 
it  becomes  intolerant  of  the  urine  and  must  be  frequently  evacuated.  It  is 
not  unusual  to  meet  with  strictured  patients  who  have  been  annoyed  by  re- 
peated calls  to  urinate  during  the  night  for  some  years,  yet  have  experienced 
no  other  anno3^ance.  Oftentimes  such  patients  are  strictured  at  the  meatus 
only.  Meatal  stricture  may  cause  frequent  urination  through  reflex  irrita- 
tion of  the  vesical  neck,  although  the  remainder  of  the  urethra  is  healthy. 

A  frequent  early  symptom  of  stricture  is  dribbling  of  urine  after  mic- 
turition. This  is  due  to  interference  Avith  contraction  of  the  accelerator- 
urince  and  compressor-urethrcB  muscles,  the  function  of  which  is  to  expel 
the  final  drops  of  urine  or  semen  from  the  canal.  As  soon  as  the  penis  is 
allowed  to  hang  downward  the  residual  urine  escapes.  It  is  not  unusual, 
even  in  stricture  of  large  caliber,  for  imperfect  ejaculation  of  semen  to 
occur,  with  dribbling  after  the  penis  becomes  flaccid. 

The  stream  of  urine  may  be  forked  or  twisted  corkscrew-fashion,  ac- 
cording to  the  form  of  the  stricture.  In  some  instances  a  straight  stream 
is  projected  from  the  meatus,  a  second  stream  falling  perpendicularly  down- 
ward. The  size  and  form  of  the  meatus  modifies  the  stream.  In  stricture 
of  large  caliber  a  narrow  meatus  may  counteract  the  effect  of  the  obstruc- 
tion and  maintain  the  natural  form  of  the  stream.  When  the  meatus  is 
large  and  its  lips  turgid  the  stream  may  be  fan-shaped,  or  several  streams 
may  run  in  different  directions.  This  sometimes  occurs  in  persons  free 
from  stricture. 

Later  on  more  or  less  straining  effort  is  required  in  micturition,  the 
abdominal  muscles  being  unconsciously  brought  into  play  to  supplement 
the  detrusor  urines.  More  or  less  atony  of  the  detrusor  soon  develops,  and 
still  greater  effort  is  required  to  empty  the  bladder.    The  strain  is  so  severe 


204  STEICTUEE    OF    THE   UEETHEA. 

in  pronounced  cases  that  hemorrhoids,  rectal  prolapse,  and  congestion  of  the 
prostate  may  develop. 

The  stream  of  urine  eyentually  becomes  very  small,  perhaps  escaping 
by  drops,  necessitating  the  expenditure  of  considerable  time  in  urination. 
Ejaculation  of  semen  may  be  interfered  with,  so  that  the  fluid,  instead  of 
escaping  normally,  is  forced  backward,  overcoming  the  resistance  of  the 
verii  montanum  and  passing  into  the  bladder.  If  this  condition  lasts  for  a 
long  time  the  function  of  the  veru  montanum  may  be  inhibited  completely 
and  permanently,  so  that  the  individual  ever  afterward  ejaculates  the  greater 
portion  of  the  semen  into  his  own  bladder.  Very  often  little  or  no  semen 
will  be  discharged  during  the  orgasm,  because  of  the  increased  turgescence 
of  the  corpus  spongiosum,  in  conjunction  with  obstruction  produced  by  the 
stricture,  occluding  the  urethra  during  erection.  The  semen  under  such 
circumstances  may  remain  in  the  urethra  to  dribble  away  as  soon  as  erection 
subsides.  Sterility  is  an  inevitable  consequence.  Partial  or  complete  im- 
potency  may  result  from  stricture  as  a  consequence  of  its  local  and  reflex 
enervating  effect.  Stricture  often  reflexly  produces  obstinate  priapism  and 
excessive  desire. 

Neuroses  from  Stricture. — A^Tiile  strictiire  is  usually  unattended  by  pain, 
there  may  be  both  direct  and  reflex  painful  symptoms.  Neuralgic  pains  in 
the  groins  or  darting  along  the  spermatic  cord,  the  front  of  the  thighs,  and 
through  the  lumbar  region  are  not  unusual.  Neuralgic  pains  in  remote 
situations  are  occasionally  experienced.  The  author  has  met  with  numerous 
cases  of  this  kind.  One  case  in  particular  was  very  interesting  in  that  ob- 
stinately recurring  angina  pectoris  was  apparently  cured  by  urethrotomy. 

The  remote  or  direct  nervous  disturbances  produced  by  stricture  are 
too  often  lost  sight  of  in  the  strictly-mechanic  aspect  of  the  condition. 
The  complex  relations  of  the  genito-urinary  apparatus  and  the  sympathetic 
deserve  attention.  The  reflex  neuroses  from  genital  irritation  in  children 
are  a  key  to  the  solution  of  many  problems  in  adult  urethral  pathology. 

There  is  a  general  impression  that  stricture  is  not  important  unless  it 
produces  urinary  obstruction.  Wlien,  however,  one  sees  vesical  atony,  in- 
continence of  urine,  impotency,  neuralgia  of  the  cord  and  testes,  lumbo- 
hypogastric  and  lumbo-sacral  neuralgia,  profound  mental  depression  and 
other  neuroses  relieved  by  urethrotomy  of  large-calibered  strictures,  the  im- 
portance of  this  question  is  suggested  in  a  very  forcible  manner.  The  rela- 
tion of  such  conditions  to  congenital  or  acquired  stricture  at  or  near  the 
meatus  is  especially  marked. 

General  malnutrition,  hypochondria,  and  malaise  are  often  noted  in 
stricture.  Nervous  irritability  is  frequently  a  prominent  feature.  Local 
pain,  referred  to  the  vesical  neck,  rectum,  perineum,  and  hypogastrium  is 
sometimes  experienced.  The  author  has  noted  glycosuria  as  a  result  of 
stricture. 

As  the  stricture  increases  in  density  and  narrowness  it  becomes  more 


NEUROSES    AND    TOXEMIA   FE03I    STEICTUEE.  205 

irritable,  and  there  is  danger  of  complete  retention  of  nrine  as  a  conse- 
quence of  deep  urethral  spasm,  with  or  without  congestion  or  inflammation 
of  the  stricture.  Acute  cystitis  may  arise  as  a  complication.  The  plus  con- 
ditions that  cause  retention  of  urine  are  usually  superinduced  by  sexual 
excesses,  intemperance,  or  exposure  to  wet  and  cold,  often  in  combination 
with  dietetic  excesses.  Gouty  and  rheumatic  patients  are  especially  liable 
to  retention.  As  a  consequence  of  retention,  rupture  of  the  urethra  behind 
the  stricture,  or  even  of  the  bladder,  may  occur,  the  urethra  being  the  more 
likely  to  give  way. 

Following  retention,  acute  cystitis  may  develop.  The  danger  of  this 
complication,  however,  depends,  to  a  great  extent,  upon  the  degree  of  care 
exercised  in  emptying  the  distended  bladder.  Infection  and  traumatism  are 
very  easily  produced. 

Toxemia  from  Stricture. — The  relations  of  stricture  to  uremia,  so  called, 
is  not  a  new  theme.  Special  attention  has  already  been  given  to  the  rela- 
tion of  the  shock  from  surgical  operations  upon  the  urethra  to  toxemia  and 
consequent  urinary  fever;  hence  the  subject  does  not  require  exhaustive 
discussion  at  this  point. 

The  relation  of  absorption  of  toxins  from  the  site  of  the  lesion  in 
stricture,  or  from  behind  it,  to  the  general  results  of  stricture  is  unques- 
tionably of  great  importance.  The  rapidity  with  which  many  constitu- 
tional symptoms  disappear  after  cure  of  deep  stricture  is  thus  easily  ex- 
plained. Urethral  chill  following  instrumentation  is  often  readily  expli- 
cable. 

The  possibility  of  mixed  infection  in  stricture  must  be  taken  into 
consideration.  Cystitis,  epididymitis,  periurethral  phlegmon,  pyelonephri- 
tis, and  other  special  phenomena  secondary  to  stricture  are  not  due  to 
direct  extension  of  inflammation,  but  probably  in  many  cases  to  secondary 
infection.  A  recent  case  of  the  author's  is  strongly  suggestive  in  this  rela- 
tion. A  patient  under  treatment  by  dilation  for  several  irritable  strict- 
ures of  comparatively  large  caliber  developed  multiple  nephric  and  peri- 
nephric abscesses,  without  intermediate  cystitis.  An  interesting  point  was 
the  fact  that  the  formation  of  the  abscesses  was  heralded  by  great  increase 
of  irritability  and  spasm  in  the  deep  urethra. 

The  all-important  point  is  the  apparent  fact  that  all  patients  with 
serious  strictures — particularly  of  the  deep  urethra — suffer  from  a  greater 
or  less  degree  of  toxemia,  and  that  many  cases  develop  secondary  single  or 
multiple  infections  of  one  kind  or  another. 

That  the  passage  of  instruments  may  precipitate  toxemia  is  granted. 
The  danger  is  enhanced  by  uncleanliness,  but  aseptic  instruments  may 
cause  it.  It  is  questionable,  however,  whether  any  instrument  passed 
through  a  diseased  anterior  urethra  can  be  aseptic  by  the  time  it  reaches 
the  deep  canal.  It  is  probable  that  strictly  aseptic  urethral  surgery  would 
involve  a  flushing  out  of  the  canal  prior  to  the  introduction  of  even  an  ordi- 


206  STKICTUEE    OF    THE    TEETHRA. 

nary  sound.  ThiS;,  of  course,  is  not  generally  done,  nor  is  it  always  prac- 
ticable. Most  surgeons,  therefore,  as  a  matter  of  routine,  are  committing 
cardinal  sins  from  the  stand-point  of  aseptic  surgery. 

The  various  complications  and  sequels  of  stricture  produce  special  and 
characteristic  modifications  of  its  symptomatology  and  course.  Thus,  a 
special  set  of  symptoms  may  occur  dependent  upon  prostatic  inflammation 
and  abscess,  vesical  and  perivesical  inflammation,  urethral  rupture  with 
infiltration  of  urine,  and  various  renal  complications. 

Diagnosis. — The  diagnosis  of  organic  stricture  can  only  be  made  by 
instrvimental  exploration.  The  facility  of  examination  depends  largely 
upon  the  condition  of  the  meatus.  It  is  obvious  that  with  ordinary  instru- 
ments a  thorough  exploration  cannot  be  made  through  a  narrow  meatus. 
For  example,  if  the  canal  be  very  large,  its  extreme  capacity  being  35 
French,  and  stricture  exists  at  different  points,  the  canal  being  contracted 
at  one  or  more  of  them  to  a  diameter  of  25  French,  the  condition  cannot 
be  readily  detected  through  a  meatus  of  a  caliber  of  20.  Otis  devised  an 
instrument  that  has  become  very  familiar  to  American  surgeons  for  the 
purpose  of  overcoming  the  obstacle  afforded  by  a  narrow  meatus.     This 


Fig.  60. — Otis's  urethrometer. 

instrument- — the  urethrometer  (Fig.  60)— consists  of  a  series  of  blades 
operated  by  a  thumb-screw  and  connected  with  a  scale-plate  or  dial,  with 
an  indicator  showing  the  exact  degree  of  expansion  of  the  blades  as  repre- 
sented by  the  French  scale.  This  instrument  is  especially  useful  when  an 
accurate  record  of  cases  is  to  be  kept. 

With  the  soft  bulbous  bougie  it  is  possible  to  accomplish  almost  as 
much  from  a  practical  stand-point  as  with  the  urethrometer.  After  a  proper 
meatotomy  the  urethra  may  be  explored  with  a  series  of  such  bougies  as 
accurately  as  is  necessary,  and  perhaps,  on  the  average,  more  intelligently 
and  safely  than  with  the  urethrometer.  Meatotomy  is  free  from  danger  if 
properly  performed,  and  almost  invariably  beneficial  in  cases  of  genito- 
urinar)'  irritation,  whether  stricture  exists  or  not.  The  author  has  seen, 
however,  one  case  in  which  considerable  sloughing  had  followed  meatotomy. 
This  was  unquestionably  due  to  instrumental  sepsis. 

The  danger  of  injury  by  the  urethrometer  may  be  obviated  to  a  great 
extent  by  covering  the  end  of  the  instrument  with  a  thin  sheath  of  rubber; 
this  does  not  usually  interfere  with  the  separation  of  the  blades,  and  pre- 
vents the  mucous  membrane's  falling  between  them.     With  some  patterns 


DIAGNOSIS    OF    STEICTUEE.  207 

of  urethrometer  and  when  the  rubber  sheath  is  thick  the  blades  of  the 
instniment  are  apt  to  twist,  corkscrew-fashion,  as  they  are  opened.  A 
vahd  objection  to  the  nrethrometer  is  that  by  its  use  strictures  of  large 
caliber  can  be  foimd  in  practically  every  urethra.  Some  nicety  of  judg- 
ment is  therefore  necessary  in  estimating  at  their  true  value  the  points  of 
narrowing  demonstrated  by  the  urethrometer.  The  author  believes  that  in 
quite  a  large  proportion  of  healthy  urethras  strictures  may  be  detected  with 
the  urethrometer  if  Otis's  method  of  examination  is  arbitrarily  followed. 
This  objection,  of  course,  falls  to  the  ground  in  cases  in  which  there  is  a 
more  or  less  definite  relation  between  the  points  of  narrowing  and  existing 
pathologic  conditions.  In  such  cases  it  is  of  little  or  no  importance  whether 
the  points  of  narrowing  were  once  physiologic  or  not;  they  have  assumed 
surgical  importance,  even  though  not  of  pathologic  origin. 

Meatotomy  is  often  a  necessary  preliminary  to  the  diagnosis  and  treat- 
ment of  urethral  disease  where  the  meatus  is  not  of  a  caliber  of  at  least  30 
French.  Some  latitude,  however,  must  be  allowed,  the  size  of  the  penis  espe- 
cially being  taken  into  consideration.  Otis  adopts  as  his  criterion  of  the  nor- 
mal urethral  caliber  the  circumferential  measurement  of  the  flaccid  penis, 
believing  that  there  is  a  constant  relation  between  the  size  of  this  organ  and 


Fig.  61. — Meatotome. 

the  caliber  of  the  canal.  This  is  probably  true  within  certain  limits,  but 
the  size  of  the  organ  is  so  variable  at  different  times  that  it  seems  hardly 
safe  to  adopt  this  as  an  arbitrary  rule.  The  mental  effects  of  simple  sound- 
ing often  cause  the  penis  to  shrink  to  very  small  dimensions.  Some  patients 
claim  that  dread  of  exposing  the  organ  produces  this  temporary  shriveling. 

In  incising  the  meatus  due  deference  should  be  paid  to  its  form.  When 
the  orifice  is  situated  low  down  upon  the  extremity  of  the  glans  it  cannot 
be  incised  so  widely  as  when  higher  up,  and,  as  a  rule,  it  will  be  found  that, 
the  lower  its  situation,  the  more  distensible  it  is  apt  to  be  and  the  less  fre- 
quently it  requires  incision.  When  practicable,  the  orifice  should  be  cut 
larger  than  the  size  which  it  is  desirable  for  it  to  retain  permanently,  as 
some  cicatricial  contraction  is  inevitable. 

Several  instruments  have  been  devised  for  meatotomy,  the  most 
familiar  being  the  histouri  cache  of  Civiale.  This  instrument  is  composed 
of  two  blades,  one  cutting  and  the  other  blunt,  separable  by  means  of  a 
screw.  Having  been  introduced  for  a  sufficient  distance  within  the  meatus, 
the  blades  are  separated  to  the  required  extent  and  the  instrument  with- 
drawn, thus  incising  the  inferior  commissure  of  the  meatus.    With  this  in- 


208 


STEICTUEE    OF    THE    IJKETHEA. 


strument  more  cutting  is  apt  to  be  done  than  is  intended,  and  it  is,  to  say 
the  least,  a  bimglesome  device  for  the  performance  of  a  very  simple  opera- 
tion. A  straight-backed,  probe-pointed,  narrow  bistoury  is  the  best  instru- 
ment for  this  purpose,  and  in  expert  hands  an  ordinary  scalpel  will  do  in 
lieu  of  a  special  instrument;  the  scalpel  may  be  used  in  combination  with 
a  director  or  its  point  covered  with  a  bit  of  wax,  thus  preventing  accidental 
injury  to  the  canal.  The  incision  should  be  made  directly  downward,  care 
being  taken  not  to  cut  through  the  floor  of  the  urethra.  Under  oocain  the 
operation  is  practically  painless.  Two  per  cent,  of  cocain  in  1-per-cent. 
carbolic  solution  or  an  8-per-cent.  oleate  of  cocain  should  be  injected  into 
the  canal  and  retained  for  about  five  minutes,  at  the  end  of  which  time  the 
part  Avill  usually  be  well  anesthetized. 

The  hemorrhage  following  meatotomy  is  sometimes  considerable.  The 
author  has  experienced  more  trouble  in  this  respect  since  using  cocain  than 
formerly.  The  drug  not  only  produces  local  anesthesia,  but  also  appears  to 
produce  vasomotor  paresis  and  venous  congestion;  the  escaping  blood  will 
be  found  to  be  dark  and  of  a  more  venous  hue  than  under  ordinary  cir- 
cumstances. Severe  bleeding  is  not  usual,  however,  at  the  time  of  opera- 
tion, as  the  drug  seems  to  act  primarily  as  an  astringent.  The  next  act  of 
urination,  however,  after  the  efi'ect  of  the  drug  has  passed  off  is  apt  to  be 
attended  by  considerable  bleeding.  If  oozing  is  obstinate  at  the  time  of 
operation  much  inconvenience  may  be  avoided  by  plugging  the  meatus. 
For  this  purpose  the  author  uses  a  wedge-shaped  piece  of  dentist's  "spunk." 
This  is  prepared  by  saturating  it  in  solution  of  bichlorid  of  mercury,  1  to 
1000,  and  drying.  The  spunk  swells  somewhat  when  it  is  wet,  and  plugs  the 
meatus  sufficiently  to  check  bleeding.  Should  it  escape  at  the  next  act  of 
urination,  as  it  is  likely  to  do,  the  patient  should  be  instructed  to  pinch 
the  under  surface  of  the  glans  at  the  site  of  the  incision  with  the  thumb 
and  finger  imtil  the  bleeding  is  arrested.  Dangerous  loss  of  blood  cannot 
occur  if  this  be  done,  and  a  few  minutes'  pressure  will  usually  check  the 
hemorrhage.  If  the  patient  be  nervous  and  excitable,  he  may  become 
frightened,  and,  losing  his  presence  of  mind,  may  not  apply  pressure  prop- 
erly, as  a  consequence  of  which  considerable  loss  of  blood  results.  An  in- 
stance of  this  kind  occurred  in  the  author's  own  practice,  in  which  suffi- 
cient blood  was  lost  to  induce  syncope.  Aside  from  the  trifling  danger 
of  hemorrhage,  the  author  has  never  seen  any  untoward  results  from 
meatotomy,  excepting  a  case  seen  in  consultation  in  which  fatal  septic 
cellulitis  developed,  and  another  in  which  sloughing  of  a  portion  of  the 
glans  about  the  incision  occurred.  Such  accidents  may  be  avoided  by  strict 
asepsis.  The  meatus  should  be  dilated  every  day  or  two  for  about  two  weeks. 
Stitching  the  edges  of  the  quasimucous  covering  of  the  glans  and  the  mucous 
lining  of  the  urethra  together,  to  insure  patency  of  the  meatus,  is  often  wise. 
The  author  has  frequently  practiced  it  with  advantage. 

If  meatotomy  is  a  preliminary  to  systematic  dilation,  it  is  well  to 


DIAGNOSIS    OF    STRICTUEE.  209 

wait  until  the  incision  has  healed  before  treating  the  urethra.  Explora- 
tion or  internal  nrethrotomy  may,  however,  be  completed  at  the  same  opera- 
tion. "\ATien  the  patient  cannot  visit  the  surgeon  frequenth^,  a  loop  of  silver 
wire  or  a  hair-pin  may  be  bent  to  the  required  size,  aseptized,  and  passed  into 
the  meatus  several  times  daily.  Careful  suturing  is  also  of  service  under 
these  circumstances. 

Aside  from  the  existence  of  obstruction  in  the  course  of  the  canal,  there 
are  several  other  points  that  may  be  determined  by  expert  exploration  with 
the  urethrometer  or  bulbs: — ■ 

1.  The  degree  of  contraction  of  the  stricture. 

2.  The  distance  of  the  stricture  from  the  meatus. 

3.  If  the  bulbous  bougie  or  urethrometer  be  passed  beyond  the  stricture 
and  then  withdrawn  until  its  shoulder  is  caught,  the  distance  of  the  poste- 
rior surface  of  the  obstruction  from  the  meatus  may  be  determined.  The 
space  included  between  the  two  measurements  corresponds  very  nearly  to 
the  width  of  the  stricture. 

4.  The  number  of  strictures.     This  is  determined  with  only  moderate 


Fig.  62. — Otis  exploring  bulbs. 

facility  with  the  bulbs,  for  the  reason  that  the  obstruction  in  the  anterior 
portion  of  the  canal  may  be  so  small  as  to  prevent  the  introduction  of  in- 
struments large  enough  to  catch  upon  the  deeper  strictures.  This  applies 
to  the  urethrometer  only  in  very  tight  penile  strictures. 

5.  Tbe  condition  of  the  urethra  posterior  to  the  stricture.  This  may 
be  approximately  determined  by  examining  the  secretion  withdrawn  from 
the  canal  by  the  shoulder  of  the  instrument.  When  this  is  thick,  with  a 
preponderance  of  purulent  qualities  and  containing  sabulous  material,  the 
existence  of  a  relatively-pronounced  degree  of  chronic  inflammation  may  be 
inferred.  When  there  is  little  or  no  secretion,  or  when  it  is  mucoid  in  char- 
acter, the  stricture  may  be  considered  to  be  moderately  passive  and  the  ure- 
thra behind  it  comparatively  healthy. 

6.  The  degree  of  congestion  present  at  the  site  of  the  stricture  may 
sometimes  be  estimated.  When  blood  appears  upon  the  shoulder  of  the 
bulb  or  escapes  from  the  meatus  after  its  withdrawal — the  exploration  hav- 
ing been  conducted  with  gentleness — considerable  congestion  at  the  site  of 
the  strictiu'e  mav  be  inferred. 


210  STEICTUEE    OF    THE   TEETHRA. 

7.  Eesiliency  or  irritability  of  the  stricture  may  be  determined.  Ee- 
siliency  is  sliown  by  the  ready  passage  of  a  comparatively  large  sound, 
■whereas  the  bulb  of  a  much  smaller  bougie  is  obstructed.  Irritability  is 
demonstrated  by  the  pain  and  spasm  excited  by  the  exploration;  possibly 
by  the  subsequent  occurrence  of  urethral  chill. 

After  exploration  of  the  urethra  for  the  first  time  the  canal  should  be 
irrigated  with  a  1  to  5000  permanganate  or  1  to  10,000  bichlorid  solution  to 
obviate  possible  chill  and  fever.  This  should  be  followed  by  10  minims  of 
eucalyptus  three  times  daily.  Diuretin  has  been  recommended  as  prevent- 
ing chill.  Should  the  patient  be  very  sensitive  or  the  stricture  severe,  it 
may  be  well  to  administer  a  dram  of  fluid  extract  of  jaborandi  or  a  h)'p- 
odermic  of  Ve  ^^  ^/ z  grain  of  pilocarpin.  By  virtue  of  their  derivative 
and  eliminant  effects  these  drugs  are  very  useful,  especially  where  uremia 
is  feared  because  of  the  existence  of  more  or  less  marked  renal  disease. 

The  patient  should  be  advised  of  the  probability  of  pain  and  smarting 
at  the  next  act  of  micturition,  and  the  possibility  of  increased  urethral  dis- 
charge. Alkaline  diluents,  balsams,  urotropin,  salol,  or  boric  acid  may  be 
administered.  Xo  further  meddling  is  usually  admissible  for  several  days 
after  the  exploration. 

Prognosis. — The  prognosis  of  stricture  involves  two  considerations: 
(1)  its  curability  and  (2)  its  danger  to  life. 

The  possibility  of  radical  cure  of  stricture  is  disputed  by  most  author- 
ities; indeed,  the  general  opinion  up  to  a  recent  date  has  been  that  without 
continual  attention  a  stricture,  once  formed,  will  sooner  or  later  give  the 
patient  trouble,  no  matter  how  skillfully  his  case  may  be  treated.  For  ex- 
ample, it  has  been  supposed  that,  as  a  rule,  a  person  who  has  been  ap- 
parently cured  of  stricture  during  early  adult  life  will  again  be  troubled  by 
the  disease  as  he  approaches  middle  age,  unless  he  has,  in  the  meantime, 
persisted  in  treatment  by  dilation,  the  necessity  for  which  increases  with 
advancing  age.  But  for  the  investigations  of  Otis  and  his  disciples  this  old- 
time  belief  would  probably  never  have  been  disputed.  It  has  been  shown 
by  them  that  quite  a  proportion  of  radical  cures  of  strictures  located  in  the 
pendulous  urethra  may  be  attained  by  dilating  urethrotomy.  No  system 
of  treatment  3'et  devised  has  been  conclusivel)^  shown  to  permanently  cure 
stricture  of  the  fixed  urethra,  with  the  possible  exception  of  perineal  sec- 
tion in  some  cases.  It  has  even  been  questioned  whether  penile  strictures 
have  ever  been  radically  cured;  but,  as.  a  number  of  cases  operated  upon 
by  dilating  urethrotom}^  have  been  examined  man^^  years  after  operation 
and  the  urethra  proved  healthy  by  careful  urethrometry,  it  is  fair  to  assume 
that  such  cases  are  radically  cured.  The  author  bases  his  opinion  not  alone 
upon  the  claims  of  Otis,  but  upon  many  years'  experience  with  the  opera- 
tion, embracing  over  fifteen  hundred  cases  of  urethrotomy.  This  point  will 
be  expatiated  u|)on  in  the  discussion  of  urethrotomy. 

It  is  not  probable  that  in  the  instances  of  apparent  cure  by  various 


PEOGXOSIS    OF    STEICTUEE.  211 

methods^,  in  cases  in  which  the  disease  recurs  sooner  or  later,  the  canal,  if 
examined  from  time  to  time  during  the  interim,  avouIcI  be  fonnd  to  be  con- 
tinnonsly  free  from  obstruction.  If  recontraction  occurs  after  complete 
dilation,  rujDture,  or  division  of  a  stricture,  such  recurrence  is  probably 
discoverable  by  thorough  exploration  within  a  very  short  time  after  the 
cessation  of  treatment.  Indeed,  it  will  be  found  on  careful  exploration  that, 
if  recontraction  occurs,  it  usually  begins  within  the  first  year  following  ap- 
parent cure.  An  individual  who  at  the  age  of  forty  presents  evidences  of 
recontraction  of  a  stricture  that  was  apparently  cured  some  years  before, 
if  carefully  examined  during  the  interim  would  probably  have  been  found 
to  have  a  certain  degree  of  narrowing  of  the  canal.  There  are  few  eases  in 
which  recontraction  does  not  commence  within  six  months  after  cessation 
of  treatment;  but  this  recontraction  may  progress  very  slowly  or  finally 
come  to  a  stand-still  until  some  years  have  elapsed.  At  any  time  during  this 
period,  however,  rapid  recontraction  may  occur  as  a  consequence  of  acute 
or  subacute  inflammation  excited  by  intemperance  or  sexual  excesses. 

Eecurrence  of  stricture  occurs  much  more  readily  in  cachectic,  stru- 
mous, gouty,  rheumatic,  and  syphilitic  patients  than  in  those  of  healthy 
constitution.  The  patient's  habits  necessarily  have  an  important  bearing 
upon  the  liability  to  recurrence. 

It  may  be  formulated  as  a  practical  rule:  1.  That  traumatic  or  chemic 
strictures  invariably  recur.  2.  That  deep  chronic  inflammatory  strictures  re- 
cm-  sooner  or  later.  If  the  urethra  is  carefully  explored  they  will  be  found 
to  have  recontracted  to  a  greater  or  less  extent  within  a  comparatively  short 
time  after  cessation  of  treatment.  3.  That  penile  strictures  rarely  disap- 
pear completely  under  dilation,  and  always  recur  unless  operated  upon 
by  urethrotomy;  they  rarely,  however,  recur,  in  the  absence  of  fresh  gonor- 
rheal infection,  when  properly,  operated  upon  by  dilating  urethrotomy. 

It  is  usually  possible  to  prevent  recontraction  of  simple  stricture  when 
the  co-operation  of  the  patient  can  be  secured.  Strict  adherence  to  the 
principles  of  genito-urinary  and  sexual  hygiene,  and  occasional  dilation 
Avitli  a  steel  sound  of  proper  size  will  generally  prevent  recontraction,  at 
least  to  a  degree  appreciable  by  the  patient. 

When  the  patient  is  able  to  secure  the  services  of  a  surgeon,  it  is  un- 
necessary for  him  to  practice  self-instrumentation;  under  other  circum- 
stances, however,  he  should  learn  to  use  the  sound  and  introduce  it  at  first 
once  a  week,  later  on  once  in  two  weeks,  and  finally  once  a  month.  Once 
an  individual  has  suffered  from  organic  stricture  the  introduction  of  the 
sound  becomes  an  important  item  in  his  toilet. 

The  prognosis  of  stricture  as  regards  danger  to  life  varies  greatly  ac- 
cording to  duration,  the  severity  of  its  complications  and  sequels,  and  the 
character  of  operations  undertaken  for  its  cure.  The  most  important  factor 
in  prognosis  is  the  condition  of  the  kidneys.  The  renal  structure  and  func- 
tion- are  almost  invariably  impaired;    indeed,  in  organic  stricture  of  lono- 


212  STEICTUEE    OF    THE    URETHEA. 

standing  such  impairment  is  to  be  inferred.  Pathologic  aberrations  of  the 
kidney  are  not  only  immediately  dangerons  to  life — either  through  acute 
exacerbations  of  inflammation  induced  by  intemperance  or  exposure,  or  by 
reflex  inhibition  of  the  function  of  the  kidney  produced  by  surgical  shock 
in  attempts  at  the  cure  of  the  stricture — but  they  bear  an  important  rela- 
tion to  the  welfare  of  the  jDatient  after  the  primary  condition  has  been 
relieved.  It  is  probable  that  a  patient  who  has  once  suffered  from  sec- 
ondary disturbance  of  the  kidney  incidental  to  organic  stricture  is  rarely, 
if  ever,  a  sound  man  again.  His  kidneys — and,  for  that  matter,  the  struct- 
ures composing  his  entire  genito-urinary  tract — are  in  a  weakened,  possibly 
degenerated,  relaxed  and  irritable  condition  that  constantly  predisposes  to 
congestion  and  inflammation.  The  slightest  excess  or  exposure  may  develop 
acute  nephritis.  Chronic  nephritis  may  supervene  at  any  time.  Pyelit's 
may  develop  after  the  patient  is  apparently  cured  of  stricture.  In  brief,  a 
patient  who  has  once  suffered  from  severe  organic  stricture  possesses  ever 
afterward  a  renal  locus  minoris  resistentue  that  is  apt  at  any  time  to  lead 
to  serious  renal  disease. 

Stricture  may  destroy  life  by  the  supervention  of  uremia  consequent 
upon  complete  inhibition  of  the  already  impaired  function  of  the  kidne3'^s. 
detention  of  urine,  due  to  inflammation  of  stricture,  may  be  fatal  through 
rupture  of  the  urethra  or  bladder,  with  consequent  extravasation  of  urine 
or  acute  cystitis — perhaps  with  gangrene  of  the  vesical  mucosa.  In  these 
-conditions,  secondary  to  retention,  the  patient  may  sink  into  a  typhoid 
state  and  die,  the  condition  ])eing  modified  b}^  a  greater  or  less  degree  of 
uremic  intoxication.  Septemia  in  its  various  forms  may  result.  Debility 
and  nervous  exhaustion  from  pain  and  loss  of  sleep,  in  coml)ination  with 
the  depressing  effects  of  urinary  intoxication  or  fever,  are  important  ele- 
ments in  all  fatal  cases. 

Xotwithstanding  the  serious  nature  of  marked  types,  it  is  surprising 
how  rapidly  some  apparently  desperate  cases  of  stricture  improve,  once 
the  obstruction  has  been  removed.  Even  when  the  kidneys  are  seriously 
impaired,  the  constitutional  symptoms  marked,  and  the  secondary  bladder- 
changes  severe,  the  patient  often  improves  with  wonderful  rapidity  as  soon 
as  the  patency  of  the  urethra  has  been  restored.  The  improvement  in  the 
patient's  general  condition  is  oftentimes  remarkable.  The  very  gradual  in- 
volvement of  the  upj)er  portion  of  the  genito-urinary  tract  in  pathologic 
conditions  secondary  to  stricture  probably  explains  the  tolerance  of  the 
patient  for  severe  renal  and  bladder-changes. 

A  condition  not  usually  recognized  in  stricture  is  the  toxemia  due  to 
the  constant  absorption  of  toxins  from  behind  the  obstruction.  This  tox- 
emia has  much  to  do  with  numerous  little  ailments  of  which  the  patient 
complains,  but  rarely  attributes  to  his  stricture;  its  cure  suggests  the  cause 
by  the  fact  of  the  sudden  and  complete  disappearance  of  the  anomalous  symp- 
toms.    This  toxemia,  too.  constitutes  a  constant  predisposition  to  urethral 


TKEATMEXT    OF    STKICTUKE.  '  213 

chill.    The  nervous  system  is  loaded  with  toxins,  so  to  speak,  and  ready  for 
the  explosion  that  instrumentation  is  oftentimes  sufficient  to  produce. 

Tkeatmext.  —  General  Management.  —  The  successful  treatment  of 
stricture  depends  not  only  upon  proper  selection  of  surgical  methods  and 
skill  in  their  performance,  but  upon  wise  general  management.  Careful 
attention,  on  the  one  hand,  or  neglect,  on  the  other,  may  determine  the 
result  of  surgical  treatment.  Thus,  dilation  may  fail,  because  of  irrita- 
bility or  resiliency  that  might  have  been  avoided  by  attention  to  certain 
details  of  general  management.  Urethrotomy,  divulsion,  or  perineal  section 
may  result  fatally,  because  the  surgeon  fails  to  study  carefully  the  conditions 
of  other  portions  of  the  genito-urinary  tract,  and  is  ignorant  of  the  general 
and  local  conditions  prevailing  at  the  time  of  operation. 

In  no  genito-urinary  disease  is  attention  to  hygiene  more  essential  than 
in  the  management  of  stricture.  Eegulation  of  diet,  tempeiate  habits,  sex- 
ual moderation,  and  avoidance  of  exposure  to  cold  and  wet  are  all-impor- 
tant. The  use  of  tobacco  should  be  interdicted  as  tending  to  induce  gen- 
eral irritability  and  hyperesthesia.  The  author  believes,  moreover,  that  it 
is  especially  irritating  to  the  genito-urinary  tract.  Chilling  of  the  feet  and 
legs  is  apt  to  be  especially  injurious,  its  effect  upon  stricture  in  the  pro- 
duction of  acute  hyperemia  and  inflammation  being  precisely  the  same  as 
in  enlarged  prostate — in  which  the  disastrous  effects  of  exposure  are  well 
known.  The  administration  of  alkalies  to  neutralize  the  urine  is  essential 
in  most  cases.  When  severe  cystitis  exists,  certain  remedies  are  beneficial 
by  preventing  decomposition  of  the  urine,  thus  lessening  its  irritating  prop- 
erties. Oil  of  eucalyptus,  boric  acid  in  10-  or  15-grain  doses  several  times 
daily,  naphthalin,  creasote  in  small  doses,  cystogen,  benzoate  and  salicylate 
of  soda,  and  small  doses  of  turpentine  are  useful  for  this  purpose.  In  the 
author's  experience  the  oil  of  eucalyptus  in  10-minim  doses  has  been  of 
especial  value.  The  activity  of  the  skin  should  be  promoted  by  Turkish 
baths  and  rubbings.  The  effects  of  sudden  atmospheric  changes  should  be 
avoided  by  wearing  warm  flannel  garments  of  uniform  weight.  Exercise 
should  be  taken  in  moderation;  fatigue  and  overexertion  should  be  avoided; 
perfect  rest  may  possibly  be  indicated. 

Certain  local  measures  are  very  essential.  A  tendency  to  spasm  and 
congestion  at  the  site  of  stricture  may  usually  be  corrected  by  daily  hot 
sitz-baths  or  the  occasional  application  of  leeches  to  the  perineum.  As  a 
matter  of  routine,  the  author  often  advises  a  hot  sitz-bath  nightly.  By 
proceeding  in  this  manner  it  will  be  found  that  the  majority  of  cases  of 
stricture  will  be  made  much  more  tractable.  In  some  cases  of  tough^ 
resilient  stricture  the  canal  may  be  much  more  readily  dilated  if  the  patient 
be  directed  to  take,  night  and  morning,  copious  injections  of  water  as  hot 
as  can  be  comfortably  borne.  These  injections  should  be  kept  up  for  half 
an  hour  at  a  time,  and  may  advantageously  be  made  antiseptic  by  the  ad- 
dition of  bichlorid  of  mercury,  1  to  20,000,  or  boric  acid  in  saturation. 


214  STKICTUEE    OF    THE    UKETHEA. 

Where  manipulations  of  tlie  canal  tend  to  excite  urethritis,  hot  bichlorid 
irrigations,  as  recommended  for  chronic  urethritis,  may  be  cautiously  em- 
ployed.    The  various  balsamic  preparations  are  of  service  in  such  cases. 

Pain  and  spasm  may  be  caused  by  every  attempt  at  dilation,  in  spite 
of  judicious  general  measures.  Under  such  circumstances  a  small  dose  of 
morphia  may  be  given,  hypodermically,  by  suppository,  or  by  the  mouth, 
shortly  before  the  operation.  "\Yhen  each  operation  tends  to  produce  chill 
or  fever,  opiates  undoubtedly  have  a  conservative  and  prophylactic  effect. 
The  author  has  found  that  in  irritable  stricture  with  a  predisposition  to 
chill  or  fever  thorough  irrigation  with  a  hot  permanganate  or  bichlorid  so- 
lution before  and  after  the  introduction  of  a  sound  or  before  cutting  oper- 
ations generally  obviates  the  diihculty.  It  will  certainly  tend  to  prevent  the 
septic  element  in  the  production  of  fever.  Quinia,  jaborandi,  eucalyptus, 
and  diuretin  are  probably  all  serviceable  as  prophylactics  against  chill,  but 
eucalyptus  is  the  most  valuable  of  all. 

Selection  of  Method. — The  various  forms  of  treatment  that  have  been 
recommended  for  stricture  are: — 

1.  Caustics. 

2.  Continuous  dilation. 

3.  Gradual  dilation. 

4.  Dilating  urethrotomy,  or  a  combination  of  section  and  rupture. 

5.  Divulsion, — i.e.,  rupture. 

6.  Internal  urethrotomy. 

7.  External  perineal  section,  or  urethrotomy:    (a)  with  a  guide;    (h) 
without  a  guide. 

8.  Electrolysis. 

9.  Subcutaneous  section. 

10.  Excision,  with  or  without  a  plastic  operation. 

Caustics. — The  treatment  of  stricture  by  caustics  is  a  relic  of  surgical 
barbarism,  and  is  unworthy  of  discussion.  The  inevitable  consequence  of 
such  atrocious  surgery  was  necessarily  the  substitution  of  a  chemic  stricture 
for  the  ordinary  type,  and,  as  is  well  known,  stricture  due  to  actual  destruc- 
tion of  tissue  is  the  most  severe  and  intractable  variety. 

All  the  other  methods  of  treatment  enumerated  have  their  advocates 
at  the  present  day — either  as  a  matter  of  routine  or  a  range  of  treatment 
from  which  to  make  a  selection — and  may  under  proper  circumstances  be 
practiced  with  advantage.  The  selection  of  the  method  is,  to  a  certain 
extent,  a  matter  of  choice  on  the  part  of  the  individual  surgeon.  The  vari- 
ous methods  will  receive  special  consideration  after  their  applicability  to 
the  various  forms  of  stricture  has  been  outlined. 

For  practical  purposes  the  surgical  treatment  of  stricture  may  be 
divided  into  that  of: — 


TEEATIIEXT    OF    STRICTUKE. 


215 


As  regards  location. 

1.  Stricture  of  the  meatus. 

2.  Stricture  of  the  penile  urethra. 

3.  Stricture  of  the  deep  urethra. 


As  regards  character. 

(a)  Simple  uncomplicated  strict- 
ure. 

(b)  Irritable  stricture. 

(c)  Eesilient  and  elastic  stricture. 

(d)  Eecurrent  stricture. 

(e)  Dense     and     hard,     tortuous 
stricture.    Multiple  stricture. 

(/)  Complicated  stricture. 
(g)  Traumatic  stricture. 

The  treatment  of  each  particular  case  is  modified  by  the  caliber  of  the 
contraction;  for  example,  in  tight  strictures  which  it  seems  advisable  to 
treat  b}^  dilation  metallic  instruments  should  not  be  used  until  a  moderate 
amount  of  dilation  has  been  attained.  The  treatment  is  further  modified 
by  the  occurrence  of  complications,  such  as  false  passages,  retention  of 
urine,  severe  cystitis  and  pericystitis,  infiltration  of  urine  and  abscess, 
fistula,  enlarged  prostate,  etc. 

Stridure  of  the  Meatus. — Irrespective  of  their  etiolog}^,  meatal  strict- 
ures require  incision.  Dilation  is  not  only  useless,  but  produces  irrita- 
tion. The  structure  of  the  meatus  is  such  that  it  cannot  be  permanently 
stretched,  and  attempts  to  do  so  not  only  produce  local  disturbance,  but 
also  reflex  irritation  and  spasm  of  the  deep  urethra.  The  proper  method 
of  performance  of  meatotomy  has  been  outlined  as  an  essential  preliminary 
to  the  proper  exploration  of  the  urethra.  Any  meatus  that  prevents  the 
introduction  of  instruments  large  enough  to  distend  the  remainder  of  the 
canal  to  its  normal  capacity  should  be  regarded  as  strictured.  As  already 
remarked,  stricture  of  the  meatus  may  be  a  relative  afi^air,  especially  the 
congenital  form,  Avhich  assumes  surgical  importance  only  when  organic  or 
functional  disease  of  the  urethra  exists  behind  it.  In  all  cases  of  obscure 
nervous  affection,  with  concomitant  urinary  or  sexual  symptoms,  it  is  wise 
to'  perform  meatotomy,  for,  whether  or  not  there  exists  apparent  irritation 
at  the  meatus,  the  effect  produced  upon  the  nervous  system  is  frequently 
strikingly  beneficial;  that  this  effect  may  sometimes  be  a  moral  one  is  ad- 
mitted;  that  it  is  not  always  psychic  is  indisputable. 

In  many  cases  of  narrow  meatus  the  urethra  behind  it  may  be  demon- 
strated to  be  pouched  by  exploration  with  a  bent  probe.  In  this  pouch 
inflammation  goes  on  indefinitel}',  its  perpetuation  being  facilitated  by  the 
accumulation  and  decomposition  of  a  few  drops  of  residual  urine.  Me- 
atotomy therefore  often  cures  a  most  obstinate  gleet. 

Stricture  of  the  Penile  Urethra. — Strictures  in  the  pendulous  urethra 
cause  more  annoyance  to  the  patient  and  more  perplexity  to  the  surgeon, 
on  the  average,  than  those  of  the  perineal  portion,  although  they  are  less 
dangerous,  and  their  direct  and  remote  results  less  serious,  than  those  oc- 


■•216  STKICTUEE    OF    THE   UEETHRA. 

curring  dee23er  doAvn.  They  rarel}^  contract  sufficiently  to  produce  serious 
obstruction  to  micturition^  and  wliere  slowly  formed  several  tight  strictures 
may  exist;,  producing  little  or  no  trouble,  and  being  discovered  accidentally 
or  during  exploration  for  the  purpose  of  determining  the  cause  of  an  inter- 
current simple  urethritis.  In  a  recent  case  of  the  author's  there  were  three 
strictures  of  the  pendulous  urethra,  the  narrowest  barely  admitting  the 
closed  blades  of  the  dilating  urethrotome.  These  strictures  had  produced 
no  inconvenience  whatever,  and  probably  would  have  remained  undiscov- 
ered for  some  time  if  the  patient  had  not,  at  the  suggestion  of  a  friend, 
submitted  himself  to  examination  for  the  purpose  of  ascertaining  whether 
a  gonorrhea  that  he  had  contracted  some  years  before  had  left  any  permanent 
results.  Such  a  passive  condition  of  penile  stricture  is,  of  course,  excep- 
tional, as  they  usually  cause  frequent  attacks  of  so-called  "bastard  clap" — 
i.e.,  simple  intercurrent  urethritis — or  an  indefinite  perpetuation  of  gleet. 

Although  stricture  in  any  portion  of  the  canal  is  apt  to  cause  vesical 
irritation,  its  liability  seems  to  be  in  direct  ratio  to  the  distance  of  the  con- 
traction from  the  meatus.  Comparatively  slight  deep  strictures  often  pro- 
duce by  direct  irritation,  through  contiguity  of  structure  and  nervous  siTp- 
ply,  and  by  infection  of  the  deep  urethra,  annoying  frequency  of  micturition. 
In  occasional  cases,  however,  this  symptom  is  the  i^rincipal  feature  of  strict- 
ure at  or  near  the  meatus. 

The  degree  of  contraction  in  penile  strictures  is  variable.  It  is  ex- 
ceptional that  such  strictures  are  so  tightly  contracted  as  those  in  the  deep 
urethra.  This  statement  may  seem  at  variance  with  the  experience  of  many 
surgeons,  but  the  discrepancy  is  explicable  by  the  fact  that  they  do  not 
recognize  that  vast  number  of  cases  in  which  stricture  of  large  caliber  exists. 
When  the  author  speaks  of  the  relative  rarity  of  penile  stricture  of  small 
caliber,  he  means  as  compared  Avith  the  total  number  observable  by  careful 
exploration  with  the  bulbous  bougie. 

Stricture  of  the  pendulous  urethra  is  quite  likely  to  be  multiple.  In- 
deed, there  are  few  cases  in  which  a  full-sized  bulb  or  the  urethrometer  fails 
to  detect  two  or  more  points  of  contraction  in  different  parts  of  the  canal. 
These  strictures  are  frequently  irritable  and  almost  always  resilient.  They 
are  a  potent  cause  of  chronic  urethritis,  and  explain  the  obstinacy  of  many 
apparently  incurable  cases  of  urethral  discharge.  Even  when  not,  strictly 
speaking,  the  cause  of  the  chronic  inflammation,  they  invariably  tend  to 
perpetuate  it.  If  the  profession  had  nothing  else  for  which  to  thank 
Otis,  it  would  be  under  lasting  obligations  to  him  for  his  demonstration 
of  the  true  pathologic  condition  in  the  majority  of  those  obstinate  cases 
of  gleet  which  have  so  long  been  the  hefe  noire  of  the  surgeon.  When  such 
.  strictures  are  irritable,  as  they  are  ver}^  apt  to  be,  very  slight  exciting  causes 
may  develop  urethritis,  the  severity  of  which  depends  upon  the  degree  of 
irritation.  In  short,  penile  strictures  of  large  caliber  constitute  a  constant 
predisposition  to  both  virulent  and  simple  urethritis. 


TEEATMEXT    OF    STEICTUEE.  317 

The  more  important  of  the  conditions  which,  in  addition  to  stricture, 
must  he  talven  into  account  in  estimating  the  causes  of  gleet  are  as  fol- 
low:— • 

1.  Constitutional  debility. 

2.  Intemperance,  alcoholic  and  sexual. 

3.  The  gouty  and  rheumatic  diatheses. 

4.  Tuberculosis  of  the  genito-urinary  tract. 

5.  Chronic  superficial  urethritis,  with  or  without  distinct  erosions. 

6.  Periurethritis  or  loss  of  elasticity, — nascent  stricture. 

7.  Folliculitis  and  chronic  inflammation  of  sinuses  and  lacunas. 

8.  Cowperitis. 

9.  Posterior  urethritis — i.e.,  prostatitis^  folliculosa. 

10.  Chronic  abscesses  from  periurethral  phlegmon. 

11.  I'rinary  fistulas. 

12.  Xeoplasmata. 

Admitting  stricture  to  be  the  most  frequent  cause  of  gleet,  the  fore- 
going etiologic  factors  are  still  worthy  of  the  most  discriminating  attention. 

One  point  that  should  be  constantly  borne  in  mind  is  that,  although 
the  urethra  will  permit  the  introduction  of  a  large-sized  steel  sound,  this 
is  no  evidence  against  the  existence  of  stricture,  for  it  will  often  be  found, 
upon  exploration  with  the  bulbous  bougie,  that  one  or  more  strictures  of 
large  caliber  exist. 

The  tendency  to  irritability  and  resiliency  of  penile  stricture  consti- 
tutes the  principal  obstacle  to  treatment  by  dilation.  Dilation  of  stricture 
in  this  portion  of  the  canal  is  usually  disappointing:  the  patient  either 
does  not  get  entirely  well  of  his  gleet  or  apparently  does  so  only  to  ex- 
perience a  recurrence  of  urethritis  from  the  slightest  exciting  cause.  The 
author  is  of  opinion  that  the  majority  of  such  strictures  are  never  thor- 
oughly cured  save  by  cutting.  Increasing  experience  has  seemed  to  show 
the  necessity  of  radical  interference  and  the  uselessness  of  temporizing  by 
dilation.  When  stricture  is  young  and  soft,- — i.e.,  of  recent  date  and  not 
yet  fully  organized, — dilation  offers  a  good  prospect  of  a  cure,  and  it  is 
but  just  that  the  patient  be  given  the  benefit  of  the  doubt  and  an  attempt 
made  to  cure  without  a  radical  operation.  In  old  cases,  no  matter  if  they 
be  apparently  slight,  dilation  is  not  apt  to  be  successful,  and,  if  it  be 
tried,  the  patient  should  be  given  to  understand  that  operation  may  become 
necessary.  Some  cases,  however,  yield  to  the  Oberlaender  method  of  com- 
bined dilation  and  irrigation. 

The  prospect  of  cure  of  penile  strictures  by  dilation  is  apparently 
proportionate  to  their  distance  from  the  meatus.  Strictures  located  any- 
where between  the  meatus  and  a  depth  of  two  and  a  half  inches  bear  al- 
most the  same  relation  to  dilation,  so  far  as  the  prospect  of  cure  is  concerned, 
as  strictures  directly  at  the  meatus. 

When  stricture  of  the  penile  urethra  is  of  small  or  moderate  caliber, — 


218  STEICTUEE    OF    THE    URETHEA. 

i.e.,  below  15  or  16  French, — it  is  often  advisable  to  begin  treatment  by 
dilation  with  soft  instruments,  in  stricture  of  the  fixed  urethra.  If  de- 
sired, the  dilation  may  be  continued  until  resiliency  of  the  stricture  begins 
to  manifest  itself;  urethrotomy  then  becomes  necessary.  Some  cases  M'ill 
apparently  dilate  readily  at  each  sitting;  yet  little  progress  is  made,  as 
recontractipn  seems  to  occur  during  the  intervals  between  seances.  The 
canal  may  be  dilated  apparently  to  its  fullest  capacity,  so  that  it  will  ad- 
mit a  large-sized  sound,  and  the  patient  discharged,  only  to  return  in  a 
short  time  with  a  recurrent  urethritis.  In  such  cases  exploration  with  bulbs 
from  time  to  time  will  show  whether  the  stricture  is  really  absorbing  or 
not.  When  improvement  is  not  steady  and  permanent,  resiliency  of  the 
stricture  may  be  suspected,  no  matter  how  large  a  sound  the  urethra  may 
admit.  The  only  recourse  in  such  eases  is  a  cutting  operation.  Eesiliency 
and  elasticity  are  rarely  met  with  in  deep  strictures.  They  are,  however, 
common  conditions  in  the  penile  portion  of  the  canal.  The  fact  that  dila- 
tion is  so  unsuccessful  in  penile  strictures  as  compared  with  those  of  the 
deep  urethra  is  probably  explicable  by  anatomic  differences  in  the  loca- 
tion of  the  contraction.  In  some  cases  of  penile  stricture  the  thickening 
and  induration  occur  principally  in  or  just  beneath  the  mucous  membrane, 
rather  than  in  the  erectile  tissue,  and,  moreover,  the  process  occurs  at  a 
point  of  normal  inelasticity  of  the  canal — i.e.,  at  a  point  which  nothing  will 
eifectually  dilate.  The  infiltration  occurring  in  deep  strictures  is  more  ex- 
tensive, and  located  principally  in  the  corpus  spongiosum,  beneath  the  mu- 
cous membrane,  at  a  point  where  the  urethral  walls  are  thick.  It  is  located, 
moreover,  upon  each  side  of  the  bulbo-membranous  junction,  and  chiefly 
anterior  to  it  rather  than  at  a  point  exactly  corresponding  to  it.  The  press- 
ure of  the  sound  produces  absorption  on  account  of  the  thickness  and 
succulency  of  the  tissues  and  the  abundance  of  absorbents.  Stricture  of 
the  deep  urethra  is  not  so  apt  to  be  produced  by  strong  injections  as  are 
penile  strictures.  Virulent  inflammation  is  not  so  severe  in  the  deep  ure- 
thra, as  a  rule,  as  in  the  anterior  portion. 

When  the  urethral  mucous  membrane  is  severely  abraded  the  conse- 
quent stricture  is  invariably  tougher  and  more  inelastic  than  under  ordi- 
nary circumstances.  Stricture  of  the  penile  urethra  resembles  traumatic 
stricture  in  this  respect;  it  will  be  found  to  be  quite  like  the  latter,  as 
regards  its  amenability  to  dilation. 

Another  point  not  generally  recognized  is  the  relative  unrest  of  penile 
stricture  incidental  to  varying  conditions  of  blood-supply. 

The  treatment  of  penile  stricture  may  be  briefly  summed  up  as  fol- 
lows : — • 

1.  Those  located  within  two  and  a  half  inches  of  the  meatus  cannot, 
as  a  rule,  be  cured  by  dilation,  but  must  be  cut. 

2.  Pronounced  cases  in  any  portion  of  the  penile  urethra  usually  de- 
mand cutting,  either  immediately  or  after  preliminary  dilation. 


TEEATMEXT    OF    STEICTURE. 


219 


^*^    I        to        I 


f  r7^© 


3.  The  treatment  of  stricture  of  small  calilDer  may  be  begun  b}^  con- 
tinuous or  gradual  dilation  with  soft  instruments  up  to  the  size  of  15  or 
16  French;  in  some  cases  it  may  be  advisable  to  continue  the  dilation 
with  steel  instruments  beyond  this  point 

— until  the  stricture  develops  irritability.  /^  >- 

4.  Strictures  of  large  caliber  of  re- 
cent formation,  and  those  consisting  of 
points  of  normal  inelasticity  that  are 
perpetuating  gleet,  may  be  treated  by 
dilation,  the  patient  being  forewarned 
that  the  treatment  is  apt  to  prove  un- 
successful and  that  urethrotomy  may  be 
necessary,  sooner  or  later,  on  account  of 

recurrence  of  urethritis.    ,In  other  words,        !^   E  ^~— ^  ^ — ^ 

the  patient  should  be  informed  that 
dilation,  although  it  may  temporarily 
relieve  the  gleet  and  other  symptoms  of 
stricture,  may  at  the  same  time  fail  to 
produce  a  satisfactory  result,  and  that 
he  will  constantly  be  predisposed  to  at- 
tacks of  inflammation  from  the  slightest 
indiscretion.  Should  the  patient  be 
satisfied  with  treatment  of  this  kind,  it 
is  hardly  wise  for  the  surgeon  to  insist 
upon  operation. 

Stricture  of  the  Deep  Urethra.  — 
Stricture  of  the  deep  urethra  implies 
contractions  involving  the  bulbo-mem- 
branous  region.  Strictures  in  this  loca- 
tion are  much  more  important  with  refer- 
ence to  serious  secondary  and  compli- 
cating conditions  that  are  intrinsically 
danoferous  to  life  than  those  occurring 
anteriorly.  As  an  invariable  rule,  the 
gravity  of  stricture  is  directly  propor- 
tionate to  its  distance  from  the  meatus. 
The  structures  surrounding  the  deep  ure- 
thra are  thick  and  vascular,  and  opera-  |U? 
tions  here  are  a  much  more  serious  matter 
than  elsewhere  in  the  canal.  Complica- 
tions of  stricture  are  not  only  most  likely 
to  arise  in  these  cases,  but  they  involve 

such  important  structures  that  they  may  result  most  disastrously.     The 
method  of  treatment  is,  therefore,  of  vital  importance,  and  in  general  it 


O 


.0® 


iV^ 


O  <3i 


w 


O  (^ 


©:: 


220  STKICTUEE    OF    THE    ITEETHKA. 

may  be  said  that,  the  more  cautious  and  conseryative  the  surgeon  and  the 
more  delicate  his  manipulations,  the  better  the  prospect  of  success.  A  care- 
ful study  of  each  case  is  necessary  to  determine  the  probable  existence  of 
serious  vesical,  and  more  particularly  of  renal,  complications  prior  to  sur- 
gical interference.  The  duration,  condition,  and  caliber  of  the  stricture  and 
the  habits  and  general  condition  of  the  patient  demand  careful  attention, 
as  they  are  criterions  for  the  selection  of  the  method  of  treatment. 

In  old  strictures  of  small  caliber,  particularly  in  intemperate  and  ca- 
chectic patients,  probable  disturbance  of  the  structure  and  function  of  the 
kidneys  is  to  be  inferred,  independently  of  the  results  of  urinalysis.  Even 
in  cases  of  deep  stricture  of  comparatively  large  caliber  care  should  be 
exercised  if  the  patient  be  at  all  broken  down  in  health,  intemperate,  or 
the  stricture  is  of  long  standing.  Although  in  the  majority  of  cases  the 
danger  of  secondar}^  and  complicating  conditions  is  proportionate  to  the 
degree  of  contraction,  it  must  be  remembered  that  the  fibrous  deposit  of 
stricture  forms  and  contracts  more  readily  in  some  patients  than  in  others; 
so  that  in  some  cases  a  stricture  of  short  duration  may  be  of  very  small 
caliber,  while  in  others  that  have  lasted  much  longer  there  may  be  little 
contraction.  Other  things  being  equal,  however,  the  tighter  the  stricture, 
the  greater  the  danger  of  renal  complications,  although  in  cases  of  sIoav- 
forming  stricture  of  large  caliber  the  bladder  and  kidneys  may  be  in  a 
much  more  serious  condition  than  in  rapidly-formed  cases  of  small  caliber. 

In  selecting  the  method  of  treatment  the  surgeon  should  remember 
that  no  method  of  management  of  deep  strictures  has  yet  been  generally 
accepted  as  yielding  a  permanent  cure.  Inasmuch  as  radical  operations  do 
not  promise  enough  to  counterbalance  their  dangers,  he  should  lean  toward 
conservatism.  If  an  approximately  successful  result  can  be  obtained  by 
simple,  conservative  measures,  it  is  certainly  unfair  to  subject  the  patient 
to  the  dangers  of  a  radical  operation. 

Simple  uncomplicated  deep  stricture  should  be  treated  by  dilation. 
If  the  stricture  be  of  small  caliber  it  may  be  necessary  to  begin  by  con- 
tinuous dilation  with  soft  bougies,  successive  instruments  being  intro- 
duced in  increasing  sizes  until  the  stricture  is  dilated  as  far  as  possible 
without  force.  If  a  soft  instrument  is  allowed  to  remain  in  the  urethra  for 
a  few  minutes,  it  will  be  found  that  the  next  larger  size  can,  as  a  rule,  be 
Cjuite  easily  introduced.  In  cases  in  which  a  small  instrument  is  introduced 
Ayith  difficulty,  it  may  be  left  in  the  canal  for  from  six  to  twenty-four 
hours,  at  the  end  of  which  time  sufficient  absorption  of  the  stricture  will 
usually  have  occurred  to  permit  of  the  introduction  of  a  larger  instrument 
and  to  permit  of  the  passage  of  the  urine  beside  the  instrument  while  in 
siiv.  This  is  a  desirable  method  in  some  cases  of  tight  stricture  in  which 
there  is  considerable  congestion  and  a  tendency  to  spasm,  in  which  it  is 
hazardous  to  introduce  and  immediately  remove  an  instrument,  because 
-  of  the  danger  of  spasmodic  or  congestive  retention  coming  on  within  a 


TEEATMEXT    OF    STEICTUKE.  221. 

few  hours  as  a  consequence  of  reaction.  After  the  stricture  has  been  dilated, 
to  a  certain  extent  tliis  is  not  so  likely  to  occur.  Gradual  dilation  per- 
formed conserYatively,  with  due  regard  to  general  and  local  measures  for 
the  correction  of  general  nervous  hyperesthesia  and  irritability  or  con- 
gestion of  the  lesion^  will  bring  about  what  is  practically  a  cure  in  by  far 
the  larger  proportion  of  deep  strictures. 

Anesthetics  are  sometimes  necessary  in  dilation.  In  many  persons, 
as  a  consequence  of  nervous  excitement  and  fear,  the  passage  of  instruments 
produces  so  much  reflex  spasm  that  a  comparatively  small  bougie  causes  con- 
siderable bruising  and  inflammation  at  the  site  of  the  stricture.  Here 
anesthetics  may  be  required;  the  preliminary  administration  of  morphin 
is,  however,  often  successful. 

It  is  exceptional  that  radical  operations  become  necessary  in  deep 
stricture,  for,  given  a  patient  who  is  able  and  willing  to  visit  the  surgeon 
or  be  visited  by  him  as  frequently  as  may  be  required,  and  an  operator 
who  has  an  abundance  of  patience  as  well  as  expertness  in  urethral  manipu- 
lations, gradual  dilation  is  generally  successful.  The  surgeon  who  regards 
the  urethra  as  an  insensate  tube  susceptible  of  the  various  operations  of 
divulsion,  cutting,  and  forcible  dilation  without  resentment  is  the  one  who 
is  able  to  report  the  largest  number  of  cases  of  radical  operations  for  deep 
stricture.  In  direct  proportion  to  the  degree  of  gentleness  and  patience 
exhibited  in  the  management  of  strictures  of  the  deep  urethra  will  be  the. 
success  achieved  in  their  treatment. 

With  all  the  patience,  perseverance,  and  gentleness  that  can  possibly  be 
exhibited,  however,  cases  occasionally  occur  that  are  insusceptible  to  treat- 
ment by  dilation.  In  some  cases  the  stricture  is  highly  contractile  and 
elastic,  and  resents  dilation  beyond  a  moderate  degree,  all  attempts  at 
further  stretching  and  absorption  being  followed  by  chill,  exacerbation  of 
urethritis,  or  painful  vesical  symptoms.  It  may  apparently  yield  quite 
readily,  and  yet  immediately  recontract  as  soon  as  the  dilation  is  sus- 
pended for  a  time.  So  much  pain  and  irritation  are  sometimes  produced 
by  instrumentation  that  it  is  impossible  to  successfully  carry  out  the  treat- 
ment by  dilation.  This  state  of  affairs  rarely  exists  in  simple  stricture,  but 
is  frequently  observed  in  complicated  forms. 

The  conditions  requiring  radical  measures  are: — ■ 

1.  Irritdble  {Ey  per  esthetic)  Stridnre. — In  this  form  the  patient  is  usu- 
ally nervous  and  irritalDle  and  the  urethra  hyperesthetic.  Every  dilation  is 
attended  by  pain  and  spasm — sometimes  with  general  convulsive  mani- 
festations— ^followed  by  chill  and  perhaps  fever.  Such  strictures  are  also 
resilient,  and  liable  to  congestion  and  inflammation;  so  that  attempts  at 
dilation  are  not  only  unsuccessful,  but  it  is  impossible  to  pass  instruments 
that  were  previously  admitted  with  only  moderate  difficulty.  Such  strict- 
ures are  usually  of  small  caliber. 

2.  Besilient  and  Elastic  Stricture. — Although  often  irritable,  this  form 


222  STEICTUEE    OF    THE    UEETHEA. 

may  be  dilated  quite  readily  until  the  urethra  is  apparently  restored  to  its 
fullest  capacity.  The  symptoms^  however,  are  not  completely  relieved,  and 
on  exploration  Avith  the  bulbous  bougie  it  is  found  that,  although  a  large- 
sized  sound  will  pass,  the  stricture  is  still  present.  This  condition  is  ex- 
ceptional in  the  deep  urethra,  being  more  frequent  in  the  penile  portion; 
still,  it  is  occasionally  met  with  deeper. 

3.  Recurrent  Stricture. — This  is  really  a  variety  of  resilient  stricture 
in  which  the  quality  of  resilienc}^  or  elasticity  does  not  immediately  mani- 
fest itself.  Such  strictures  recontract  shortly  after  cessation  of  treatment, 
either  spontaneously  or  from  some  slight  cause.  As  a  rule,  resilient,  elastic, 
and  recurrent  strictures  do  not  exhibit  their  evil  propensities  until  they 
have  been  fairly  well  dilated,  when  they  become  exceedingly  stubborn. 
Very  often  they  are  of  comparatively  large  caliber.  Other  things  being 
equal,  such  behavior  is  more  likely  to  occur  in  stricture  of  large  caliber. 
Like  the  preceding  form,  recurrent  stricture  is  most  frequent  in  the  penile 
portion,  although  occasionally  met  with  in  the  deep  urethra. 

Recurrence  of  stricture  is  most  rapid  and  certain  in  gouty  or  rheu- 
matic subjects.  The  habits  of  the  patient  have  a  very  important  bearing 
upon  this  form  of  stricture. 

4.  Very  Hard  Stricture  of  C ariilaginous  Consistency  and  Long  Dura- 
tion.— Strictures  of  this  kind,  although  often  traumatic,  may  arise  from  the 
ordinary  cause, — i.e.,  virulent  urethritis.  They  are  usually  tortuous,  and 
instruments  are  passed  with  difhculty.  Dilation  cannot  be  carried  beyond 
a  moderate  degree,  owing  to  the  density  of  the  quasicicatricial  stricture- 
tissue.  Strictures  of  this  kind  will  neither  dilate  permanently  nor  can 
absorption  be  induced  in  them  by  pressure.  Deep  strictures,  involving  one- 
half  or  three-fourths  of  an  inch  or  more  of  the  canal,  are  likely  to  present 
these  characteristics. 

5.  Hard,  Tortuous,  Complicated  Stricture. — Strictures  of  this  kind  are 
apt  to  be  complicated  by  serious  retention,  urethral  rupture,  and  urinary 
infiltration  or  formation  of  fistulas.  There  may  be  considerable  plastic 
exudate,  not  only  in  the  urethra,  but  in  the  cellular  tissue  of  the  perineum. 
There  is  invariably  a  formation  of  dense  fibro-connective  tissue  about  these 
parts  if  fistulas  have  developed. 

6.  Cases  Demanding  Economy  of  Time,  or  Where  the  Condition  of  the 
Patient  Urgently  Demands  Immediate  Relief. — ISTon-resident  patients  who 
cannot  afford  the  time  involved  in  gradual  dilation  must  be  included  un- 
der this  head. 

Irritable,  resilient,  and  recurrent  strictures  of  large  caliber  in  the  deep 
urethra  are  best  treated  by  external  section,  although  the  combined  method 
of  urethrotomy  and  divulsion — a  relatively-small  nick  being  made  in  the 
strictured  tissue,  just  sufficient  to  facilitate  rupture- — sometimes  gives  good 
results.  American  surgeons,  however,  are  properly  abandonins:  all  internal 
cutting  operations  in  the  deep  urethra.     When  such  strictures  are  of  only 


TEEATMENT    OF    STRICTUEE.  223 

moderately  large  caliber,  the  tissues  being  relatively  dense  and  cartilaginous, 
jDerineal  section  is  to  be  preferred,  although  simple  divulsion  is  often 
successful. 

In  cases  of  irritable  stricture  radical  operations  are,  on  the  average, 
productive  of  less  constitutional  disturbance  than  repeated  attempts  at  dila- 
tion. The  contracted,  resilient  stricture-tissue  is  so  hyperesthetic  that  the 
slightest  attempt  to  stretch  it  may  result  seriously,  whereas  division  by  in- 
cision or  rApture  relieves  the  hyperesthesia  at  once  and  produces  compara- 
tively little  irritation,  the  danger  from  o]^>€ration  being  rather  of  a  direct 
character  and  incidental  to  the  possible  occurrence  of  sepsis  than  due  to  any 
remote  impression  produced  through  the  medium  of  reflex  nervous  dis- 
turbance. 

The  difference  in  results  obtained  by  stretching  a  contracted  and  highly- 
.sensitive  fibrous  and  muscular  structure  and  completely  dividing  it  is  well 
illustrated  in  certain  cases  of  talipes,  torticollis,  and  other  conditions  in 
which  fibrous,  tendinous,  and  muscular  structures  are  shortened,  and  per- 
haps thickened,  by  interstitial  connective-tissue  or  fibrous  deposit.  When 
dilation  produces  severe  pain  and  reflex  spasm,  with  perhaps  alarming 
constitutional  manifestations,  further  attempts  are  contra-indicated,  and 
more  radical  measures,  involving  rupture  or  incision,  are  demanded.  Com- 
plete rest  for  some  days  or  weeks  occasionally  allays  irritability  and  facili- 
tates dilation. 

Very  hard,  cartilaginous  deep  strictures  of  long  standing,  whether  com- 
plicated or  not,  require  perineal  section,  especially  in  cases  attended  by  seri- 
ous bladder  complications.  The  simpler  varieties  of  complicated  stricture 
do  not  necessarily  demand  such  radical  measures.  In  these  severe  forms  of 
stricture  divulsion  or  internal  urethrotomy  are  very  dangerous  as  well  as 
unreliable.  There  is  great  danger  of  hemorrhage,  which  is  difficult  to  con- 
trol on  account  of  the  depth  of  the  operative  lesion  and  the  induration 
of  the  bleeding  tissue.  There  are  also  the  special  dangers  of  septic  infec- 
tion, infiltration  of  urine,  abscess,  and  fistula,  due  to  laceration  of  the 
stricture  and  surrounding  parts,  these  complications  being  favored  by  the 
heat  of  the  tissues  and  the  unavoidably  sept-ic  condition  of  the  wound. 

Internal  incision  of  dense  stricture  of  the  deep  urethra  is  unsuccessful 
because  it  is  impossible  to  introduce  a  cutting-blade  of  sufficient  size  to 
accomplish  thorough  division.  To  accomplish  complete  division  the  incision 
must  in  some  cases  necessarily  extend  entirely  through  the  urethral  wall. 
The  relation  of  urethrotomy  to  deep  strictures  is  not  the  same  as  it  bears 
to  those  occurring  in  the  penile  portion.  In  the  latter  the  blade  of  the 
urethrotome,  when  properly  used,  nearly  or  quite  divides  the  strictured 
tissue,  which  involves  in  many  instances — invariably  in  strictures  of  large 
caliber — only  the  mucous  membrane  and  a  more  or  less  superficial  layer 
of  the  tissues  beneath  it.  It  is,  of  course,  admitted  that  many  cases  of 
penile  stricture  are  extensively  indurated,  but  these  are  exceptions  to  the 


224  STRICTURE    OF    THE    URETHRA. 

rule.  In  the  dense  varieties  of  deep  stricture  tlie  urethrotome  merely 
makes  a  comiDaratively  superficial  incision  in  the  strictured  tissue^  and  does 
not  completely  divide  it.  It  is  obvious  that  complete  rupture  of  such  strict- 
ures is  impossible  without  considerable  injury  to  the  corpus  spongiosum. 
Taking  these  things  into  consideration,  external  perineal  section  is  to  be 
recommended  because  (1)  it  completely  divides  the  stricture;  (2)  complete 
relief  of  retention  is  secured;  (3)  perfect  drainage  and  comparative  asepsis 
are  provided  for;  (4)  hemorrhage  is  easy  of  access  and  control;  (5)  the 
result  of  the  operation  is  better  and  much  more  easily  maintained  perma- 
nently by  occasional  dilation  than  after  deep  internal  operations. 

The  author  believes  that  perineal  section  is  less  dangerous,  on  the 
average,  even  in  the  slighter  forms  of  deep  stricture,  than  either  internal 
urethrotomy  or  divulsion. 

Cases  demanding  immediate  interference  because  of  retention  had  best 
be  treated  by  external  perineal  section.  If,  however,  the  patient  can  be 
under  the  control  of  the  surgeon  and  there  is  a  prospect  of  a  favorable 
]'esult  from  conservative  measures,  the  case  should  be  temporized  with  until 
such  time  as  it  is  practicable  to  begin  dilation.  The  aspirator  is  sometimes 
warrantable  in  such  eases.  In  certain  exceptional  selected  cases  divulsion 
may  be  judicious.  If  the  stricture  be  of  small  caliber,  external  perineal 
section  should  be  performed.  In  some  cases  of  deep  stricture,  especially 
when  complicated  by  retention,  electrolysis — i.e.,  galvanism — is  a  service- 
able preliminary  to  other  treatment. 

Treatment  of  Stricture  by  Sijstematlc  Dilation. — Instruments. — The 
instruments  used  for  dilation  of  stricture  are  of  three  varieties:  (a)  soft 
and  flexible  bougies;  (b)  fine,  stiff,  hair-like  bougies  known  as  filiforms; 
(c)  metallic  sounds.  Soft  bougies  are  of  various  patterns,  the  French  and 
English  varieties  being  chiefly  used.  They  are  made  in  two  forms,  viz.: 
{a)  with  a  plain  conic  point  and  (b)  with  an  olivary  tip.  Their  flexibility 
varies  according  to  composition.  The  best  bougies  (the  French)  are  com- 
posed of  a  web  of  woven  material  covered  with  rubber.  The  plain  conic 
form  is  the  most  serviceable.  The  olive-pointed  variety  is  designed  chiefly 
to  avoid  passing  the  instrument  into  the  crypts  or  enlarged  follicles  so  fre- 
quently found  in  chronic  urethral  disease. 

In  selecting  French  bougies  the  least  flexible  should  be  chosen;  they 
are  apt  to  be  more  durable  and  serviceable  than  the  very  flexible  forms, 
which  are  so  limp  that  they  bend  upon  themselves  when  they  come  in  con- 
tact with  the  slightest  obstruction.  The  French  bougies  are  preferable  to 
the  English,  but,  unfortunately,  they  are  not  so  durable.  Filiform  bougies 
— so  called  because  of  their  thread-like  fineness— are  composed  of  -rubber, 
catgut,  or  whalebone.  The  whalebone  variety  is  the  best.  The  rubber 
variety  is  of  the  same  composition  and  construction  as  the  ordinary  French 
or  English  bougies.  Some  forms  of  soft  bougie  are  made  with  a  small, 
screw-threaded  cap,  which  may  be  fastened  to  a  urethrotome  or  divulsor, 


TEEATMENT    OF    STEICTUEE. 


325 


the  bougie  acting  as  guide  or  conductor  for  the  larger  instrument.  Soft 
bougies  of  considerable  length  may  be  procured  when  necessary  as  guides 
for  cutting  or  divulsing  instruments.  The  whalebone  variety  is  stifEer  and 
more  durable  than  those  composed  of  rubber,  and  if  dipped  in  hot  water  the 
point  may  be  molded  into  any  form  that  may  be  deemed  useful  in  ayoiding 
urethral  diverticula  which  might  prevent  engagement  of  the  bougie  in  the 


Fig.  64. — Olive-tipped  soft  bougie. 

orifice  of  the  stricture.  AVhen  a  filiform  is  used  as  a  guide,  a  tunneled  in- 
strument may  be  passed  it.  The  late  Professor  W.  H.  Van  Buren  was  the 
inventor  of  the  first  tunneled  instruments  ever  used,  and  should  have  due 
credit  for  them.  Some  care  is  necessary  in  the  selection  and  preservation 
of  filiform  guides.  They  should  be  at  least  18  inches  in  length,  smooth, 
and  perfectly  straight,  save  when  necessary  to  bend  them  for  adaptation  to 
tortuous  strictures.    A  partial  fracture  of  a  filiform  bougie  is  a  warning  to 


Fig.  65. — Soft  straight  catheters. 

condemn  the  instrument.  Any  irreo'ularities,  inequalities,  or  rough  surfaces 
of  the  filiform  guide  are  likely  to  catch  the  loop  of  tunneled  instruments, 
thus  obstructing  their  passage;  oftentimes  a  filiform  guide  is  cut  through. 
Soft  bougies  and  catheters  are  not  so  easily  managed  as  stiff  metallic 
instruments;  their  flexibility  permits  them  to  bend  upon  themselves  when 
they  come  in  contact  with  a  tight  stricture.  It  is  difficult,  however,  to  pro- 
duce injury  with  them,  and,  as  instruments  should  be  coaxed,  not  forced. 


iG^ 


aett=3— - 


Fig.  66. — Screw-tipped  guides. 

through  a  stricture,  their  function  in  the  treatment  of  close  strictures  is 
very  important. 

In  warm  weather  gum  instruments  are  apt  to  become  soft  and  sticky; 
this  may  be  prevented  by  dusting  with  talcum.  Care  should  be  taken 
to  have  them  perfectly  free  from  oil  before  laying  them  awa}^  else  they 
■will  become  soft  and  worthless.     They  tend  to  grow  brittle  with  age,  and 


226 


STEICTUEE    OF    THE   UEETHEA. 


are  easily  broken.  Care  should  therefore  he  taken  to  guard  against  the 
iTse  of  superannnated  instruments.  In  cleansing  soft  instniments  alcohol 
shonld  be  used.  Strong  solutions  of  carbolic  acid  should  be  avoided;  if 
allowed  to  remain  in  such  solutions  for  a  few  minutes  they  become  rough, 
thus  impairing  their  facility  of  introduction. 

Soft  instruments  may  be  introduced  with  the  patient  in  either  the  re- 
cumbent or  standing  posture,  the  latter  being  sometimes  preferable.  In 
practicing  dilation  soft  instruments  should  be  used  wheneyer  a  size  smaller 
than  16  French  is  required.    In  tight  stricture  with  pain  and  spasm  during 


Fig.  67. — Bank's  whalebone  bougies. 


instrumentation  soft  instruments  are  absolutely  essential  until  the  urethra 
has  been  dilated  moderately,  after  which  steel  instruments  may  usually  be 
substituted. 

Sounds  are  usually  composed  of  inflexible  metal.  There  is  an  old- 
fashioned  variety  composed  of  soft  metal  capable  of  being  bent  in  any  form, 
the  use  of  which  is  very  limited. 

The  most  important  features  of  the  metallic  sound  are  the  shape  and 
length  of  its  point.  The  English  (or  Thompson)  instrument  has  a  point 
the  diameter  of  which  is  but  slightly  less  than  its  shaft,  being  consequently 


Fig.  68. — Correct  cairve  for  instruments. 


comparatively  blunt.  The  curve  is  rather  long,  and  the  point  is  at  right 
angles  with  the  shaft.  Tan  Buren  devised  a  modification  of  the  English 
instrument  that  is  ver}^  popular  among  American  surgeons.  The  point  of 
this  instrument  is  smaller,  more  conic,  and  the  curve  shorter  than  that 
of  the  English  instrument.  It  is  advantageous  on  account  of  its  short  curve, 
which  makes  the  instrument  easily  controlled  by  the  hand.  There  is  a 
compensatory  disadvantage  in  the  fact  that  the  point  is  so  small  and  conic 
that  injury  in  the  hands  of  a  careless  operator  is  produced  more  readily 
than  by  the  English  instrument.    As  the  sound  acts  somewhat  on  the  prin- 


TKEATJIEXT    OF    STEICTUEE. 


227 


ciple  of  a  wedge,  it  is  obvious  that  stretching  the  stricture  is  more  likely 
to  he  forced  hy  the  x\merican  than  by  the  English  instrument. 

Care  should  be  taken  that  the  sounds  are  perfectly  clean — i.e.,  aseptic 
— before  their  introduction  into  the  canal.  Should  they  become  rough 
they  should  be  thrown  aside  or  polished  anew.  It  is  desirable  for  the  sur- 
geon to  have  a  second  set  of  sounds  Avith  a  very  short  curve  and  conic 
point  for  use  in  the  jDcndulous  urethra. 

In  the  majority  of  cases  of  stricture  it  is  not  necessary  to  pass  instru- 
ments into  the  bladder  in  order  to  secure  the  maximum  of  beneficial  effect 
from  dilation.  Prostatic  and  vesical  irritation  is  very  often  caused  by  me- 
chanic injury  incidental  to  the  passage  of  sounds  in  the  treatment  of  strict- 
ure located  several  inches  anterior  to  the  vesical  neck.  After  some  years  of 
careful  study  of  urethral  sounds  the  author  has  devised  an  instrument  that 
seems  eminently  satisfactory.  This  instrument  is  much  shorter  and  its 
point  blunter  than  those  in  common  use.  The  point  of  the  sound  should 
not  be  too  tapering,  or  it  will  be  necessary  to  introduce  it  some  distance 


Fig-.  69. — Author's  urethial  sounds 


beyond  the  obstruction  before  its  greatest  diameter  is  brought  to  bear  upon 
the  stricture.  A  blunt  point  similar  to  that  of  the  author's  sound  is  of 
some  advantage  in  diagnosis.  While  by  no  means  so  accurate  as  the  bulbous 
bougie,  it  is  far  more  serviceable  than  the  ordinary  conic  sound. 

The  proper  form  for  metallic  instruments,  as  already  stated,  is  that 
IviKnvn  as  the  Thompson  curve.  This  corresponds  to  the  curve  of  a  circle 
3  V4  inches  in  diameter.  According  to  Thompson,  the  proper  length  of  arc 
of  such  a  circle  for  the  beak  of  sounds  is  that  subtended  by  a  chord  2  '/^ 
inches  long.    A  shorter  curve,  however,  is  better,  for  reasons  already  given. 

Continuous  dilation  is  serviceable  in  tight  stricture  where  instru- 
mentation is  difficult.  In  such  cases  considerable  nicety  of  judgment  is 
required  as  to  the  advisability  of  withdrawing  an  instrument  once  it  has 
])assed  the  obstruction.  Continuous  dilation  is  tempting  under  such  cir- 
cumstances, and  the  surgeon  is  certainly  excusable  for  hesitancy  in  decidin'^- 
to  remove  an  instrument  that  perhaps  required  the  utmost  patience  and 
perseverance  for  its  introduction.    It  is  usually  safe  to  leave  a  small  soft  or 


228  STEICTUEE    OF    THE    UKETHRA. 

filiform  bougie  in  tlie  uretlira  after  it  has  j^assed  tlie  stricture,  and,  as  a 
rule;,  tlie  effect  is  beneficial,  for  in  a  short  time  it  will  be  found  that  more 
or  less  absorption  has  occurred,  and  the  bougie  which  was  previously  tightly 
grasped  has  become  loosened.  It  may  now  be  removed  and  a  larger  instru- 
ment introduced. 

The  first  instrument  passed  should  be  tied  in  the  bladder,  and  allowed 
to  remain  in  situ  for  from  twelve  to  twenty-four  hours,  during  which  time 
the  urine  usually  escapes  beside  it.  When  the  first  instrument  is  removed 
the  next  larger  size  should  be  immediately  introduced,  as  a  certain  degree 
of  recontraction  maj'  occur  in  a  few  minutes  and  prevent  the  introduction  of 
another  instrument.  A  certain  amount  of  urethritis  is  caused  by  the 
bougie,  Init  this  is  rarely  severe,  and  subsides  very  soon  after  gradual  dila- 
tion has  been  substituted  for  the  continuous  method.  Continuous  dila- 
tion should  be  practiced  until  Xo.  10  or  12  French  can  be  introduced,  after 
which  gradual  dilation  with  the  soft  instruments  should  be  substituted. 
AVhen  practicable,  a  very  small  catheter  may  be  passed  instead  of  a  bougie 
to  facilitate  evacuation  of  the  bladder  in  case  retention  should  occur.  At 
the  second  passage  of  instruments,  as  a  rule,  a  small  catheter  or  bougie  may 
be  introduced,  even  though  at  the  first  operation  it  may  have  been  dilhcult 
to  pass  even  a  filiform. 

Tlie  principal  objection  to  continuous  dilation  is  the  tendency  to 
cystitis.  If  a  catheter  has  been  inserted  this  may  be  obviated  by  daily  ves- 
ical irrigations  of  the  viscus  with  a  mild,  warm,  antiseptic  solution.  Slough- 
ing of  the  urethral  mucous  membrane  with  perineal  abscess  and  fistula  has 
been  known  to  occur  as  a  result  of  continuous  dilation.  Such  an  accident 
can  only  occur  from  extreme  distension  by  the  forcible  introduction  of 
an  instrument  larger  than  necessary. 

Gradual  dilation  is  generally  the  most  practicable  method  of  treating 
stricture.  It  should  be  begun  on  about  the  third  day  after  preliminary  ex- 
ploration has  determined  the  location  and  various  qualities  of  the  stricture. 
It  may  be  necessary  to  vary  the  length  of  interval  following  preliminary 
exploration  according  to  the  amount  of  reaction.  Much  depends  upon  the 
tolerance  of  the  urethra  and  the  nervous  susceptibility  of  the  patient.  If 
a  preliminary  meatotomy  has  been  performed,  it  is  often  well  to  wait  imtil 
the  meatus  has  completely  healed  before  going  on  Avith  the  treatment  of 
the  deeper  portions  of  the  canal,  unless  the  necessity  is  urgent,  as  in  very 
tight  strictures,  in  which  retention  may  occur  at  any  time.  The  irritation 
of  the  raw  cut  surface  produced  by  the  passage  of  the  sound  invariably 
gives  rise  to  more  or  less  reflex  spasm  of  the  deep  urethra.  x\s  a  conse- 
quence irritation  and  inflammation  of  the  stricture  may  be  produced  even 
by  instruments  of  small  size. 

If  treatment  by  gradual  dilation  be  decided  on,  it  should  begin  with 
the  insertion  of  a  small  sound  at  the  next  sitting  following  the  preliminary 
exploration,  or  as' soon  as  the  meatus  has  healed,  as  the  case  may  be.     The 


TEEATMENT    OF    STEICTUKE.  239 

first  instmment  passed  should  be  small  enougli  to  pass  easil3^  In  this  way 
the  sensibility  of  the  stricture  may  be  blunted  to  a  certain  extent  and  the 
canal  opened  up,  facilitating  the  passage  of  an  instrument  large  enough  to 
distend  the  stricture.  After  the  withdrawal  of  the  small  instrument  a 
second  should  be  inserted  that  is  large  enough  to  distend  the  stricture  with- 
out the  exhibition  of  force  in  its  introduction.  If  pain  and  spasm  result, 
the  sound  should  be  immediately  withdrawn.  If,  however,  the  urethra  be 
tolerant,  it  should  be  allowed  to  remain  for  a  minute  or  two  to  secure  the 
full  effects  of  the  distension.  It  should  now  be  removed  and  the  next 
larger  size  introduced  in  the  same  manner.  It  is  rarely  advisable  to  use 
more  than  two,  or  at  most  three,  sounds  at  a  single  operation,  a  single  in- 
strument being  best  if  the  stricture  be  very  irritable.  If  the  surgeon  un- 
dertakes to  hurry  matters  severe  urethritis,  prostatitis,  cystitis,  epididy- 
mitis, or  urinary  fever  may  result,  or  a  tractable  stricture  become  irritable 
and  resilient.  Any  of  the  accidents  mentioned  ma}^  prove  a  serious  com- 
plication, and  will  inevitably  delay  treatment.  It  is  the  author's  opinion 
that  the  surgeon  is  often  responsible  for  congestion,  inflammation,  irri- 
tability, and  resiliency  of  stricture  occurring  in  the  course  of  treatment 
by  dilation.  One  of  the  cardinal  principles  that  should  guide  the  operator 
is  the  avoidance  of  force,  conjoined  with  efforts  to  "coax"  the  stricture  to 
a  cure.  Nothing  is  gained  by  torturing  the  sensitive  tissues  by  the  intro- 
duction of  too  large  and  too  many  instruments. 

The  preliminary  administration  of  anod3'nes,  the  continuous  use  of 
nervous  sedatives  and  antispasmodics,  and  even  anesthetics,  are  frequently 
useful  adjuncts  to  dilation. 

The  sudden  acquirement  of  a  spasmodic  element  in  a  stricture  under 
treatment  may  indicate  renal  complications.  In  a  case  of  the  author's  the 
formation  of  perinephric  abscess  was  heralded  by  severe  spasm  of  a  strict- 
ure that  was  under  treatment  by  dilation. 

At  the  next  sitting  dilation  should  be  begun  with  an  instrument  a 
size  smaller  than  the  largest  previously  introduced.  Should  the  urethra 
be  very  irritable,  it  ma}^  be  necessary  to  again  pass  as  a  preliminary  measure 
a  very  small  instrument  for  the  purpose  of  blunting  sensibility.  Two  sizes 
should  be  introduced  as  before. 

The  frequency  of  dilation  should  vary  according  to  the  exigencies 
of  each  particular  case.  Many  surgeons  in  their  enthusiasm  for  a  speedy 
cure  of  the  stricture  are  tempted  to  introduce  instruments  too  frequently. 
It  is  not  unusual  to  meet  with  cases  that  have  been  tortured  into  irritability 
and  resiliency,  by  the  daily  introduction  of  sounds.  While  it  is  permissible 
in  very  tight  strictures  to  introduce  soft  instruments  every  day,  it  is  rarely 
beneficial,  and  usually  injurious,  to  pass  metallic  instruments  oftener  than 
once  in  three  days.  In  many  cases  once  in  four  or  five  days  or  more  is 
sufficient. 

Some  patients  complain  greatly  of  pain  and  severe  spasm,  with  per- 


230  STRICT L'EE    OF    THE    UEETHKA. 

liajjs  chill  and  fever,  if  the  sound  be  introduced  oftener  than  once  a  week. 
Quite  prolonged  intervals  of  rest  are  essential  in  some  cases. 

It  is  necessary  in  all  tight  strictures  to  begin  treatment  with  soft  in- 
struments, jDcrhaps  by  continuous  dilation.  After  the  stricture  has  been 
dilated  to  the  caliber  of  about  IG  French,  steel  instruments  ma}"  be  sub- 
stituted. "With  small  steel  instruments  there  is  great  danger  of  traumatism. 
Such  instruments  do  not  pass  by  their  own  weight,  but  require  some  force. 
The  degree  of  pressure  exerted  requires  some  nicety  of  judgment;  it  takes 
very  little  force  to  drive  the  jDoint  of  a  metallic  instrument  through  the 
urethral  wall,  causing  a  false  passage.  In  some  instances  it  is  wise  to  use 
soft  instruments  up  to  a  considerable  size  before  substituting  sounds. 

Dilation  acts  in  two  ways:  (1)  by  mechanically  stretching  the  strict- 
ure, thus  temporarily  increasing  its  caliber:  (2)  by  producing  absorption  of 
the  advcutitious  tissue,  with  resultant  permanent  dilation.  In  order  that 
this  may  occur  a  certain  degree  of  reaction  should  follow  the  introduction 
of  the  sound.  It  is  upon  increase  of  nutrition  of  the  part,  incidental  to 
slight  hyperemia  resulting  from  mechanic  stretching,  that  the  cure  de- 
pends. This  reaction  must  be  kept  within  bounds,  however,  for  when  it 
merges  into  inflammation  the  stricture  can  only  be  aggravated  by  sound- 
ing. Slight  increase  in  discharge  following  the  use  of  the  sound  is  usual; 
a  marked  increase  is  an  indication  that  imdue  inflammation  has  been  ex- 
cited, and  should  serve  as  a  caution  against  further  dilation  until  the  re- 
action has  subsided. 

For  a  short  time  after  the  introduction  of  the  sound  the  flow  of  urine 
is  facilitated  by  the  mere  mechanic  stretching  produced  by  the  instru- 
ment. This  increased  caliber  persists  for  twenty-four  to  thirty-six  hours, 
at  the  end  of  which  time  reaction  occurs,  with  coincident  hyperemia  and 
increased  activity  of  the  processes  of  nutrition  in  the  diseased  tissues.  A 
moderate  amount  of  swelling  results  that  serves  to  diminish  the  caliber  of 
the  stricture.  Within  a  day  or  two,  however,  absorption  begins  and  con- 
tinues for  several  days,  at  the  end  of  which  time  recontraction  commences. 
If  a  sound  be  introduced  during  the  time  reaction  is  at  its  height,  more  or 
less  acute  inflammation  is  excited  and  the  case  aggravated. 

As  reaction  diminishes  the  benefits  of  absorption  are  apparent  in  the 
increased  size  of  the  stream.  If  the  operation  be  successful,  the  stream  of 
urine  will  be  larger  than  before.  The  rapidity  with  which  reaction  comes 
on,  its  degree,  and  the  amount  and  duration  of  absorption  vary  greatly.  A 
careful  study  of  each  case  teaches  the  surgeon  when  another  operation  is 
permissible.  If  the  canal  be  dilated  in  a  routine  manner  and  increasing 
degree  every  few  days,  many  disappointments  will  be  experienced.  Each 
case  is  a  law  unto  itself  and  should  be  treated  upon  its  own  merits.  In 
some  cases  the  urethra  will  not  tolerate  any  increase  of  the  size  of  the  in- 
strument for  several  successive  operations,  it  being  necessar}'  to  introduce 
the  same  instrument  several  times. 


TEEATMENT    OF    STEICTL'EE. 


231 


The  proper  method  of  introduction  of  the  sound  is  an  important  matter 
for  consideration.  It  is  to  be  remembered  in  this  connection  that  the  final 
steps  of  the  operation  of  urethral  dilation  are  not  always  necessary.  Un- 
less there  is  some  special  indication  for  deep  dilation,  the  membrano-pro- 
static  urethra  should  not  be  entered  by  the  soimd.  The  necessity  for  deep 
dilation  is  regailated  by  the  location  of  the  stricture  and  the  condition  of 
the  posterior  urethra.  The  patient  had  best  be  in  a  partially-recumbent 
posture,  with  the  knees  flexed,  the  feet  at  rest,  the  thighs  flexed  slightly 
on  the  abdomen,  and  the  shoulders  somewhat  raised.  The  first  step  in  the 
introduction  of  the  sound  is  to  grasp  the  penis  in  the  left  hand  and  with 
the  right  hand  insert  the  sound  into  the  urethra  to  a  depth  corresponding 


Fig.  70. — First  position  in  introducing  a  sound. 


to  a  point  just  past  the  junction  of  the  straight  with  the  curved  portion  of 
the  instrument.  The  shaft  should  be  held  close  to,  and  parallel  with,  one 
or  the  other  groin — according  as  the  surgeon  is  right-  or  left-  handed. 
(Fig.  70.)  The  operator  should  stand  upon  the  corresponding  side  of  the 
patient.  The  sound  is  now  dipped  well  down  into  the  perineal  urethra 
until  its  point  has  almost  reached  the  opening  in  the  triangular  ligament, 
the  handle  being  raised,  but  still  held  parallel  with  Poupart's  ligament. 
(Fig.  71.)  The  instrument  is  now  swept  toward  the  median  line,  its  point 
being  simultaneously  dipped  still  farther  downward  until  the  bulbo-mem- 
branous  opening  is  reached.  (Fig.  72.)  It  is  finally  swept  downward  toward 
the  feet.  If  for  any  reason  exploration  of  the  bladder  is  desired,  the  final 
stage  of  the  introduction  is  required  (Fig.  73),  the  shaft  of  the  sound  being 


232 


STEICTURE    OF    THE   URETHRA. 


brought  down  until  almost  in  line  with  the  central  axis  of  the  patient's  body. 
In  most  cases  this  is  not  necessary.  When  at  an  angle  of  about  45°  the 
point  of  the  sound  is  usually  at  the  orifice  of  the  bladder  or  just  within  it. 
This  suffices,  as  a  rule,  in  treating  stricture  and  chronic  urethritis.  Gath- 
ering the  testes  up  in  the  free  hand,  and  holding  them  up  until  the  sound 
finally  enters  the  bladder,  is  a  useful  maneuver.  Pressure  upon  the  pubic 
region  to  relax  the  subpubic  ligament  is  often  useful,  but  rarely  necessary. 
The  introduction  of  the  sound  usually  occasions  more  or  less  smart- 
ing and  a  variable  degree  of  pain,  most  marked  as  the  instrument  ap- 
proaches the  vesical  neck.  As  it  passes  over  this  highly  sensitive  part  more 
or  less  nausea  and  faintness,  possibly  s3?ncope,  may  be  produced. 


Fig.  71. — Second  position  in  introducing  a  sound. 


Care  should  be  taken  that  the  instrument  is  well  warmed  and  lubricated 
before  introduction,  else  pain  and  spasm  will  be  greatly  enhanced.  The 
best  lubricant  is  albolene  with  mercury  bichlorid,  1  in  1000,  in  combina- 
tion with  5  to  10  grains  of  cocain  to  the  ounce.  Should  medicated  applica- 
tions to  the  canal  be  required  after  removal  of  the  sound  for  the  purpose 
of  curing  refractory  gleet,  glycerin  should  be  used  as  a  lubricant.  Oils  coat 
the  surface  of  the  mucous  membrane  and  prevent  effective  action  of  astrin- 
gents.    Lubrichondrin  is  a  new  and  satisfactory  lubricant. 

Accidents  and  Morhid  Effects  Sometimes  Incidental  to  Dilation.  — 
Urinary,  or  urethral,  fever  in  its  various  phases  is  one  of  the  most  frequent 


TREATMENT    OF    STEICTUKE. 


233 


and  serious  results  that  may  follow  dilation  of  stricture.     It  has  already 
been  fully .  considered  in  a  preceding  chapter. 

Hemorrhage. — Hemorrhage  is  a  frequent  result  of  the  introduction  of 
urethral  instruments.  As  a  rule,  its  occurrence  is  an  indication  that  undue 
force  has  been  used.  In  most  cases  where  dilation  causes  hemorrhage, 
the  instrument  used  is  too  large  or  too  much  force  has  been  exhibited. 
An  instrument  that  will  enter  the  bladder  by  its  own  weight  will  rarely 
produce  bleeding,  as  the  stretching  of  the  stricture-tissue  is  accomplished 
in  a  gentle  manner.  In  very  tight  strictures  and  those  in  which  there  is 
considerable  congestion  and  spasm  the  introduction  of  any  instrument, 
however  small,  is  liable  to  produce  hemorrhage.     When,  therefore,  the  in- 


Fig.  72. — Third  position. 


troduction  of  an  instrument  that  will  enter  the  bladder  without  the  em- 
ployment of  force  is  followed  by  bleeding,  that  there  exists  considerable 
congestion  at  the  site  of  the  stricture  may  be  inferred.  The  hemorrhage, 
'per  se,  is  not  injurious;  on  the  contrary,  it  is  beneficial  by  producing  local 
depletion.  If,  however,  it  results  from  forcible  instrumentation,  the  ex- 
ces.sive  reaction  folloAving  the  traumatism  more  than  counterbalances  any 
benefit  that  could  be  derived  from  local  abstraction  of  blood. 

Some  cases  in  which  congestion  predominates  will  bleed  occasionally 
after  urination,  particularly  if  the  patient  has  recently  indulged  in  inter- 
course or  become  sexually  excited.  Such  strictures  are  particularly  apt  to 
occur  in  intemperate  individuals  and  syphilitics.  Under  such  circum- 
stances the  utmost  gentleness  in  the  introduction  of  instruments  will  not 


234 


STRICTUEE    OF    THE    UEETHEA. 


prevent  more  or  less  bleeding.  It  is  rarely  if  ever  necessary  to  treat  the 
hemorrhage;  on  the  contrary,  it  should  be  allowed  to  continue  within 
reasonable  limits.  Should  it  become  excessive,  however,  the  application 
of  the  cold-water  coil,  penile  bandage,  or  ice-bag  will  usually  check  it. 

False  Passages. — These  result  from  instrumentation  more  frequently 
than  is  generally  believed.  They  are  due  to  the  passage  of  the  instrument 
through  the  urethral  walls  into  the  surrounding  tissues.  The  mucous  mem- 
brane only  may  be  torn  up,  in  which  case  the  passage  rarely  extends  for  a 
great  distance,  or  the  corjjus  spongiosum  may  be  entirely  traversed  and  the 
tissues  of  the  perineum  entered.  The  danger  of  their  occurrence  is  greatest 
with  small  metallic  instruments,  it  being  difficult  to  produce  them  by  means 


Fig.  73. — Fourth  and  final  position. 


of  flexible  bougies  or  catheters.  The  common  English  catheter  with  the 
stylet  is,  however,  nearly  as  dangerous  as  metallic  instruments. 

In  pack-thread  or  bridle  strictures  numerous  urethral  pockets  may 
exist,  or  there  may  be  a  sort  of  membranous  diaphragm  thrown  obliquely 
across  the  urethra  in  such  fashion  that  the  instrument  impinges  upon  it 
just  at  its  junction  with  the  urethral  walls,  instead  of  entering  the  orifice 
of  the  stricture.  Under  such  circumstances  the  conditions  necessary  to 
the  production  of  a  false  passage  are  very  favorable,  and  it  takes  but  little 
force  to  jDerforate  the  urethra. 

Symptoms. — The  occurrence  of  this  accident  is  usually  quite  evident. 
The  surgeon  is  usually  conscious  of  having  used  considerable  force  or  of 
carelessness  in  respect  to  conforming  the  instrument  to  the  natural  direc- 


TKEATMENT    OF    STKICTUEE. 


235 


tion  of  the  urethra.  The  obstruction  suddenly  yields  to  the  pressure,  and 
the  direction  of  the  handle  of  the  instrument  shows  that  the  point  is  out 
of  the  proper  line.  If  the  handle  of  the  instrument  be  rotated  between 
the  thumb  and  fingers,  it  will  be  found  that  the  point  is  fixed,  thus  showing 
conclusively  that  it  cannot  have  entered  the  bladder.  When  the  bladder 
is  entered  the  point  of  the  instrument  is  usually  freely  movable  within  the 
viscus,  and  there  is  no  sense  of  resistance  imparted  to  the  handle  when 
rotated. 

Exceptionally  the  instrument  may  not  only  traverse  the  urethral  walls, 
but  pass  onward  until  the  bladder  is  perforated.  Coincidently  with  altera- 
tion in  the  direction  of  the  instrument  the  patient  complains  of  severe  pain 
and  perhaps  impending  syncope,  and  may  be  conscious  that  something  has 


Fig.  74. — False  passage  in  stricture.    A  catheter  in  tlie  abnormal 
channel.     (After  Dittel.) 


been  torn.  Free  bleeding  usually  results.  On  rectal  examination  the  beak 
of  the  instrument  is  found  in  the  connective  tissue  of  the  vesico-rectal 
septum. 

False  passages  are  most  often  formed  in  the  deep  urethra,  as  it  is  here 
that  the  lever  action  of  the  sound  is  most  powerful  and  strictures  so  tight 
as  to  demand  small  instruments  are  usually  found.  It  is  not  easy  to  pro- 
duce false  passages  in  the  pendulous  urethra,  as  the  point  of  the  instrument 
is  continually  under  control  of  the  fingers  and  its  proper  direction  is  easily 
maintained. 

The  seriousness  of  false  passages  is  proportionate  to  their  distance  from 
the  meatus.  Their  direction  is  usually  to  one  side  of  the  canal.  They  ma}', 
however,  perforate  it  above  or  below.  When  above  they  are  not  likely  to 
penetrate  for  a  great  distance  on  account  of  the  firmness  of  the  tissues. 


236  STEICTUKE    OF    THE    UKETHKA. 

The  corpus  spongiosum,  or  even  the  prostate^  may  be  completely  perforated 
when  the  false  passage  occurs  below. 

The  character  of  the  perforation  has  also  mnch  to  do  with  the  degree 
of  danger.  If  the  false  passage  enters  the  corpus  spongiosum  and  rnns 
along  the  urethra,  perhaps  to  open  again  into  the  canal,  or  the  bladder 
be  entered  after  a  lateral  lobe  of  the  prostate  has  been  perforated,  the  dan- 
ger to  life  is  comparatively  slight.  When,  however,  the  instrument  passes 
clear  outside  the  corpus  spongiosum  into  the  vesico-rectal  areolar  tissue, 
serious  extravasation  of  urine  may  result,  with  consequent  inflammation, 
suppuration,  or  perhaps  gangrene. 

Old  false  passages  are  occasionally  very  annoying  and  frequently  not 
only  interfere  with  treatment,  but  prevent  complete  relief  of  symptoms, 
even  though  the  caliber  of  the  canal  be  restored.  As  a  rule,  the  history 
justifies  a  suspicion  of  the  formation  of  a  false  passage  or  passages  at  some 
previous  instrumentation.  The  abnormal  direction  of  the  sound,  failure 
to  enter  the  bladder,  and  the  peculiar  gristly  sensation  imparted  to  the  in- 
strument are  often  sufficient  to  indicate  its  existence.  Oftentimes  the  pa- 
tient is  aware  of  the  presence  of  false  passages.  Occasionally  he  will  feel 
that  the  abnormal  channel  has  been  penetrated  by  the  instrument  AAdien  its 
course  is  not  evident  to  the  surgeon.  In  some  instances  only  the  most 
careful  study  of  the  symptoms  and  course  of  the  case  will  enable  us  to 
determine  the  true  condition.     In  some  cases  a  diagnosis  cannot  be  made. 

Acute  inflammation  of  the  urethra,  prostate,  Madder,  and  epididymis  is 
a  by  no  means  infrequent  complication  of  stricture  jDroduced  by  instru- 
mentation. Following  dilation  of  stricture,  there  is  always  moderate  re- 
action ajoproximating  inflammation.  This,  however,  should  properly  be 
limited  to  the  stricture  itself.  There  may  occur,  on  the  other  hand,  a  sharp 
urethritis.  Much  depends  on  the  condition  of  the  urethra  at  the  time  of 
dilation;  of  more  importance,  however,  is  the  cleanliness  of  the  sound 
and  the  degree  of  gentleness  displayed  in  its  introduction. 

Inflammation  of  the  prostate,  incidental  to  rough  instrumentation,  is 
an  occasional  result  of  dilation.  It  should  be  remembered  that  the  pros- 
tate is  invariably  congested  and  irritable,  as  a  consequence  of  bruising  dur- 
ing frequent  and  spasmodic  efforts  at  urination.  In  the  presence  of  this 
condition  comparatively  slight  traumatism  may  cause  prostatitis.  This 
may  be  acute  from  a  single  act  of  violence  or  ma}^  appear  in  a  subacute 
or  chronic  form  consequent  upon  repeated  bruising  and  irritation.  Ab- 
scess may  occur,  especially  if  trauma  and  infection  be  produced  by  a  septic 
sound. 

Cystitis  in  the  course  of  stricture  arises  in  several  Avays:- — - 

1..  It  may  be  due  to  injury  done  the  vesical  neck  by  large  instruments. 

2.  It  may  result  from  prolonged  contact  of  instruments  with  the  ves- 
ical neck  in  continuous  dilation.  Ulceration  of  the  vesical  walls  may  result 
from  pressure  produced  by  the  point  of  faulty  sounds. 


OPERATIVE    TREATMENT    OF    STRICTURE.  237 

3.  Pre-existing  chronic  inflammation  of  the  vesical  neck,  due  to  direct 
infection  or  extension  of  inflammation  from  stricture,  may  be  so  enhanced 
by  the  introduction  of  instruments  that  acute  generalized  cystitis  and  per- 
liaps  pericystitis  results. 

4.  A  small  quantity  of  poisonous  material,  formed  by  bacterial  evolu- 
tion posterior  to  the  stricture,  is  carried  by  the  point  of  the  instrument  to 
the  vesical  neck  and  sets  up  acute  infectious  inflammation. 

The  relation  of  bacterial  organisms — not  necessarily  specific — to  the 
morbid  processes  at  the  site  of  stricture  and  to  cystitis  is  a  very  important 
one. 

5.  Poisonous  materials — i.e.,  bacterial  organisms  or  their  products- 
may  be  conveyed  to  the  cavity  of  the  bladder  by  unclean  instruments. 

Epididymitis  is  one  of  the  most  frequent  complications  of  stricture. 
It  may  be  produced  in  two  ways:  (a)  by  the  production  of  acute  inflamma- 
tion at  the  site  of  the  stricture,  which  extends  down  to  the  mouths  of  the 
ejaculatory  ducts  and  thence  to  the  epididymis;  (h)  by  the  conveyance  of 
organic  poisons  to  the  mouths  of  the  ejaculatory  ducts  via  the  sound  or 
catheter. 

It  is  possible  that  the  testis  may  become  involved  via  lymphatic  in- 
fection. 

The  various  complications  of  stricture  may  usually  be  avoided  if  the 
patient  keeps  quiet,  is  temperate,  and  follows  directions  implicitly,  and, 
more  important  still,  if  the  surgeon  is  gentle  in  his  manipulations  and  ab- 
solutely cleanly  as  regards  his  instruments. 

It  is  desirable  for  patients  under  treatment  for  stricture  to  wear  a  sus- 
pensory bandage  if  the  testes  be  sensitive. 

OPERATIVE    TREATMENT    OF    STRICTURE. 

DivuLSiox. — Divulsion  of  stricture  consists  of  rapid  and  forcible  dila- 
tion with  the  object  of  rupturing  the  morbid  tissues. 

Various  instruments  have  been  devised  for  divulsion.  Some  of  these 
consist  of  sliding  tubes  of  varying  caliber  that  are  forcibly  introduced 
over  a  central  guide.  Another  variety  splits  the  stricture  after  the  fashion 
of  a  wedge.  Still  another,  and  the  most  popular  variety,  consist  of  several 
parallel  blades  separable  by  means  of  a  powerful  screw. 

Divulsing  tubes  were  first  used  by  Desault  something  like  a  hundred 
years  ago.  They  are  used  in  the  following  manner:  A  small  bougie  is  in- 
troduced into  the  bladder  as  a  guide,  over  this  an  open-ended  catheter  is 
passed,  and  over  this  another  catheter  or  tube  a  trifle  larger,  as  much  force 
as  is  necessary  being  used.  A  succession  of  tubes  of  increasing  size  are 
passed  imtil  the  urethra  is  dilated  to  its  fullest  capacity. 

Divulsion  upon  the  wedge  principle  was  first  recommended  by  Rey- 
band;  it  has  been  modified  to  a  certain  extent  by  Holt,  whose  instrument 
consists  of  two  grooved  blades  of  strong  metal  joined  at  their  points.     Be- 


238  STEICTUKE    OF    THE    UEETHEA. 

tween  the  two  points  and  fastened  to  them  at  their  point  of  juncture  is  a 
wire  that  acts  as  a  guide;  over  this  wire  a  tube  of  considerable  size  is  forcibly 
passed.  This  separates  the  blades  and  splits  the  stricture.  It  is  claimed 
by  Holt  that  the  rupture  produced  by  the  instrument  does  not  extend  be- 
yond the  morbid  tissue,  the  healthy  urethra  not  being  injured.  The  ac- 
curacy of  this  statement  is  questionable.  It  is  hardly  possible  for  stricture 
of  any  extent  to  be  ruptured  without  injury  to  the  urethra. 

Divulsors  with  separable  blades  are  the  most  popular  instruments  for 
rupturing  stricture. 

Various  patterns  of  screw-divulsor  have  been  devised;  they  have  been 
made  with  two,  three,  and  four  blades.  The  best  device  is  probably  that 
of  Sir  Henry  Thompson,  which  has  two  strong,  separable  parallel  blades. 
This  instrument  may  be  used  for  the  purpose  of  rapid  dilation  by  sloAvly 
separating  the  blades  with  successive  turns  of  the  screw,  or  it  may  be  used 
to  rupture  a  stricture  by  se^jarating  the  blades  as  rapidly  as  possible.  When 
the  operation  is  slowly  done  little  bleeding  occurs,  and  there  is  probably 
little  or  no  laceration  of  the  urethral  walls. 

Divulsion  has  not  been  very  popular  in  America.  It  still,  however, 
has  many  advocates  in  England  and  on  the  Continent,  and  is  being  revived 
in  the  East  in  this  countr}'.  Tlue  operation  seems  unsurgical,  and  unless 
considerable  damage  is  done  at  the  site  of  the  lesion  is  apt  to  fail  of  its 
object.  Eapid  stretching,  unless  attended  by  complete  rupture  of  the  strict- 
ure, will  usually  only  inflame  and  irritate  the  stricture-tissue  and  make  it 
resilient  and  elastic.  It  is,  perhaps,  safer  than  internal  urethrotomy  in  the 
deep  urethra,  but  external  perineal  section  is  far  safer  than  either  in  severe 
stricture.^ 

Eesilient,  elastic,  and  recurrent  stricture  of  large  caliber  in  the  deep 
urethra  may  sometimes  be  divulsed  with  advantage.  In  these  strictures 
gradual  dilation  is  usually  carried  on  until  the  morbid  tissue  is  very  slight 
in  amount  and  involves  but  a  superficial  extent  of  the  urethra  and  its  sub- 
lying  connective  tissue.  Under  such  circumstances  urethrotomy  may  be 
objected  to  on  account  of  the  danger  of  hemorrhage,  and  external  perineal 
section  for  such  slight  lesions  is  likely  to  be  considered  severe.  Under  these 
circumstances  divulsion  is  a  useful  operation. 

Divulsion  should  be  followed  by  gradual  dilation.  A  steel  sound  of 
moderate  size  is  to  be  introduced  four  or  five  days  after  the  operation,  the 
time  varying  with  the  amount  of  inflammation  resulting  from  rupture  of 
the  stricture.  An  instrument  should  be  passed  at  first  every  third  da}^,  the 
intervals  being  subsec|uently  lengthened. 


^  It  is  only  fair  to  state  that  several  of  our  ablest  American  surgeons  are  now 
advocating  divulsion  and  commending  the  operation  very  highly.  The  author,  how- 
ever, still  believes  that  the  tearing  and  bruising  of  what  must  be  a  septic  field  is  not 
in  accord  with  modern  suroical  art. 


INTERNAL    UEETHROTOMY.  239 

Internal  Ueetheotomy. — Internal  urethrotomy  consists  in  division 
of  the  stricture  by  incision.  Urethrotomes  are  practically  of  three  kinds, 
viz.:  (1)  those  which  cut  the  stricture  from  before  backward;  (2)  those 
which  cut  from  behind  forward;  (3)  those  which,  in  addition  to  a  cutting- 
blade  passed  through  a  hollow  central  guide,  have  two  separable  blades, 
the  object  of  which  is  to  complete  the  operation  by  divulsing  or  tearing 
any  of  the  fibers  of  the  stricture  that  are  not  divided  by  the  incision.  The 
only  reliable  instruments  for  internal  urethrotomy  are  those  of  Maisonneuve 
and  Otis  and  their  modifications.  The  most  reliable  and  satisfactory  in- 
strument is  the  Otis  dilating  urethrotome. 

Maisonneuve's  instrument  cuts  from  before  backward,  and  is  service- 
able for  division  of  deep  strictures.  It  consists  of  a  hollow  tube  with  a 
central  slit  corresponding  to  the  roof  of  the  urethra.  Triangular  knives  of 
different  sizes  fastened  to  a  wire  shaft  are  passed  along  the  central  tube 
after  its  introduction  into  the  bladder  until  the  stricture  is  divided.  This 
urethrotome  is  supplied  with  a  screw-tip  to  which  a  filiform  bougie  may  be 
attached.     The  principal  objection  to  the  use  of  this  instrument  is  that  it 


Fig.  75. — Maisonneuve's  urethrotome. 

never  divides  the  stricture  completely  unless  a  very  large  blade  is  used,  in 
which  event  there  is  more  cutting  than  necessary,  and  serious  hemorrhage 
may  result. 

The  latest  modification  of  Maisonneuve's  urethrotome  consists  of  a 
straight  timneled  shaft  with  a  secondary  blade,  the  two  being  separable  by 
a  powerful  screw.  The  cutting-blade  runs  in  a  groove  upon  the  central 
shaft.  Attached  to  the  handle  near  the  screw  is  a  dial-plate.  By  this  in- 
strument the  urethra  may  be  cut — or  dilated  and  cut — to  a  caliber  of  45 
French. 

General  anesthesia  is  only  occasionally  necessary  for  internal  ure- 
throtomy. In  very  nervous  patients  it  may  be  essential.  It  must  be  remem- 
bered, however,  that  a  general  anesthetic  should  be  avoided  where  possible, 
especially  in  chronic  genito-urinary  disease,  because  of  possible  evil  effects 
upon  the  kidnej'^s.  Cocain  has  probably  been  responsible  for  certain  acci- 
dents, especially  in  urethral  surgery,  but  if  used  in  relatively-weak  solu- 
tions it  is  safer  than  general  anesthesia.  Internal  urethrotomy  may  ordi- 
narily be  performed  with  a  1-per-cent.  solution  of  cocain  in  a  1-per-cent. 


2-iO  STEICTUEE    OF    THE    URETHEA. 

solution  of  carbolic  acid.  Four  per  cent,  slioulcl  not  be  exceeded  in  the 
urethra.  The  carbolic  acid  is  antiseptic,  more  or  less  anesthetic,  and  suf- 
ficiently astringent  to  limit  the  action  of  the  cocain.  The  canal  should  first 
be  flushed  with  solution  of  mercury  bichlorid  in  a  strength  of  1  to  20,000 
to  1  in  10,000  or  potassium  permanganate  1  to  5000. 

Operation.  —  The  number  of  strictures  and  their  distance  from  the 
meatus  having  been  estimated,  the  dilating  urethrotome  (Fig.  76)  is  passed 
down  until  the  point  upon  the  shaft  at  which  the  blade  will  first  appear 
when  vrithdrawn  is  about  half  an  inch  behind  the  stricture.  The  blades 
are  now  separated  by  turning  the  screw  until  tension  of  the  stricture  is 
evident;  the  cutting-blade  is  then  steadil}^  and  with  moderate  rapidity 
withdrawn.  The  dilating  blades  are  now  separated  to  the  required  extent. 
They  are  finally  screwed  together  again  and  the  instrument  withdrawn, 
care  being  taken  not  to  catch  the  mucous  membrane  between  the  blades 
during  withdrawal.  Exploration  with  a  full-sized  bulb  should  now  be  made 
to  determine  whether  the  strictures  have  been  completely  divided.  If  the 
urethra  is  not  perfectly  free,  the  urethrotome  should  again  be  used.     The 


The  Otis  dilating  urethrotome. 


operation  is  completed  by  the  passage  of  a  full-sized  sound.  After  the  op- 
eration the  urethra  should  be  irrigated  with  hot  saturated  solution  of  boric 
acid  or  mercury  bichlorid  1  to  20,000.  The  patient  should  be  put  to  bed, 
and  if  there  be  much  hemorrhage  an  ice-bag  or  the  cold-water  coil  applied. 

The  determination  of  the  size  to  which  the  urethra  should  be  enlarged 
involves  some  nicety  of  judgment.  The  only  fixed  standard  that  has  been 
suggested  is  that  of  F.  N.  Otis,  already  alluded  to.  According  to  Otis,  the 
average  size  of  the  urethra,  as  determined  by  numerous  measurements  with 
the  urethrometer,  is  as  follows:  When  the  circumferential  measurement  of 
the  penis  is  three  inches  the  urethra  should  admit  a  sound  No.  30  French. 
With  each  one-eighth  of  an  inch  increase  in  circumference  the  urethra 
should  increase  one-third  of  a  millimeter  in  diameter;  i.e.,  one  size  larger 
upon  the  French  scale.  Thus,  the  penile  circumference  being  3  Vs  inches, 
the  urethra  should  admit  31  French;  with  a  circumference  of  3  ^/^  inches, 
32,  and  so  on.  A  circumference  of  4  ^/^  inches  is  rarely  exceeded.  In  such 
cases  the  urethra  should  admit  at  least  40  French. 

One  of  the  principal  objections  to  the  Otis  system  is  that  it  is  liable 
to  apparently  demonstrate  the  existence  of  stricture  of  large  caliber  at 


INTEENAL    UEETHEOTOMT,  241 

points  of  normal  relative  inelasticity  of  the  canal.  There  is,  however,  as 
a  rule,  no  danger  and  no  disagreeable  results  to  be  apprehended  from  dilat- 
ing the  urethra  after  preliminary  incision  to  as  large  caliber  as  possible 
with  the  Otis  instrument.  Occasional  cases  may  arise,  however,  in  which 
damage  might  be  done  by  a  too-arbitrary  application  of  the  Otis  measure- 
ments. 

It  is  generally  practicable — and,  as  a  rule,  advantageous — to  enlarge 
the  urethra  as  recommended  by  Otis  where  urethrotomy  is  necessary,  but  it 
by  no  means  follows  that  the  size  attained  at  the  time  of  operation  should 
be  maintained.  In  fact,  it  will  often  be  found  impracticable  to  maintain 
a  caliber  of  more  than  32  to  35  French  even  where  the  urethra  has  been 
incised  and  stretched  to  the  fullest  capacity  attainable  by  the  dilating 
urethrotome  (45  French).  The  urethral  enlargement  secured  by  operation, 
even  when  thoroughly  done,  is,  to  a  certain  degree,  temporary  in  character, 
being  partly  dependent  upon  overstretching  of  the  muscular  fibers  of  the 
urethral  walls.  This  makes  the  urethra  flaccid,  and  for  a  few  days  a  large- 
sized  sound  will  be  admitted;  after  a  time,  however,  the  tonicity  of  the 
urethra  is  restored,  and  as  a  consequence  an  instrument  which  it  was  prac- 
ticable to  introduce  immediately  after  operation  can  no  longer  be  passed 
without  undue  force.  In  fact,  the  caliber  of  the  urethra  which  it  is  prac- 
ticable to  permanently  secure  by  operation  is  usually  some  sizes  smaller  than 
that  primarily  secured. 

There  has  recently  developed  considerable  opposition  to  urethrotomy 
on  the  part  of  certain  authors  who  treat  upon  genito-urinary  surgery. 
Much  of  this  opposition  is  based  upon  underestimation  of  the  normal  ure- 
thral caliber.  Of  the  recent  treatises  in  which  the  subject  is  discussed,  two 
are  especially  noteworthy.  In  one  work  the  maximum  urethral  caliber  is 
given  as  31  French,  while  in  the  other  30  is  claimed  to  be  the  maximum, 
and  the  assertion  is  made  that  an  individual  whose  urethra  will  admit  26 
French  has  no  stricture  worthy  of  the  name.  It  should  go  without  the  say- 
ing that  inasmuch  as  a  normal  caliber  of  35  to  40  French  is  by  no  means 
extraordinary,  many  cases  in  which  26  or  even  31  French  can  be  passed  may 
still  require  surgical  attention.  There  is  necessarily  a  wide  discrepancy  of 
opinion  between  operating  and  non-operating  surgeons.  The  author  is  of 
opinion  that,  the  meatus  being  sufiiciently  dilatable,  there  are  few  cases  in 
which  the  normal  male  urethra  will  not  admit  from  30  French  upward. 

In  performing  internal  urethrotomy  the  rule  should  be:  (a)  to  cut 
downward  at  the  meatus  and  a  short  distance  within  it;  (b)  to  cut  upon  the 
roof  of  the  canal  in  the  penile  urethra. 

Untoward  Effects  of  Internal  Urethrotomy. — Considerable  inflammation 
sometimes  follows  dilating  urethrotomy.  This  may  give  rise  to  chordee 
lasting  for  some  little  time,  perhaps  leaving  a  curvature  that  persists  for 
some  weeks  or  even  months  after  the  operation-wound  has  healed. 

There  is  no  question  but  that  cases  occasionally  arise  in  which  a  greater 


242  STEICTURE    OF    THE   UEETHEA. 

or  less  degree  of  deformity  results  after  internal  urethrotomy.  This  is 
usually  temporary  and  slight,  but  has  been  the  jorincipal  reason  for  the 
terrific  howl  that  has  been  sent  up  by  the  anti-operation  faction  of  the  pro- 
fession against  internal  urethrotomy.  Failure  to  cure  chronic  gleet  is  fre- 
quently offered  as  an  objection  to  the  operation.  The  author  is  not  aware  of 
any  other  operation  in  which  infallibility  and  absolute  freedom  from  dis- 
agreeable results  is  demanded  in  every  case  operated  upon.  Such  a  demand 
in  the  case  of  internal  urethrotomy  is  hardly  logical  or  fair.  A  discussion  of 
the  various  arguments  pro  and  con  in  relation  to  internal  urethrotomy 
would  merely  consume  space.  The  author  simply  states  that  in  an  experi- 
ence of  nearly  twenty  years  with  internal  urethrotomy  he  has  not  only  had 
no  occasion  to  alter  his  views  upon  the  subject,  but,  on  the  contrary,  has 
become  more  firmly  convinced  of  the  solidity  of  the  foundation  upon  which 
the  doctrines  enunciated  by  Otis  were  constructed. 

The  author  has  observed  imperfect  erection  in  several  cases  which 
lasted  a  year  or  more  after  urethrotomy.  The  complaint  usuall}^  made  is 
that,  while  the  rest  of  the  organ  becomes  normally  erect,  the  glans  remains 
soft  and  flabby.  This  is  only  explicable  on  the  ground  of  cicatricial  inter- 
ference with  the  circulation  of  the  organ.  The  occurrence  is  very  rare,  but 
none  the  less  demands  consideration.    Eecovery  is  the  rule. 

After-treatment  in  Dilating  Urethrotomy. — The  prevailing  tendency  is 
to  regard  the  operation  of  urethrotomy  as  trivial,  requiring  little  attention 
to  details.  The  surgeon  often  operates  at  his  office  and  allows  the  patient 
to  go  about  at  will.  This  is  injudicious.  Where  possible,  the  patient 
should,  as  a  rule,  be  put  to  bed  for  from  four  or  five  days  to  a  week. 

Cases  occasionally  occur  in  which  there  is  little  bleeding  at  the  time 
of  operation,  but  very  free  hemorrhage  comes  on  during  the  night  as  a  con- 
sequence of  erection.  This  makes  the  application  of  cold  a  necessity.  In 
a  case  of  the  author's  severe  hemorrhage  followed  an  erection  two  weeks 
after  operation.  In  addition  to  the  application  of  cold,  anaphrodisiacs  may 
be  given  to  prevent  hemorrhage.  Ergot,  potassium  bromid,  and  gelsemium 
meet  the  indications  admirably.  A  suppository  of  hyoscyamus,  morphia, 
and  monobromicl  of  camphor  is  often  of  great  service.  The  bromids  should 
be  given  in  large  doses. 

It  is  the  author's  custom  to  give  oil  of  eucalyptus  in  10-minim  doses 
three  or  four  times  daily  after  a  urethrotomy.  This  drug  keeps  the  urine 
bland  and  aseptic.  Boric  acid,  cystogen,  sodium  benzoate,  gaultheria,  and 
salol  are  also  of  service. 

Dilation  is  usually  carried  on  too  vigorously  after  urethrotomy.  The 
danger  of  hemorrhage,  urethritis,  and  curvature  of  the  penis  is  directly 
proportionate  to  the  frequency  of  dilation  after  operation.  The  best  re- 
sults follow  infrequent  dilation  beginning  on  the  third  day — or  even  later 
if  bleeding  be  profuse — dilation  being  repeated  every  third  day  for  a  week, 
and  every  fourth  or  fifth  day  thereafter.    There  is  no  danger,  as  a  rule,  in 


INTERNAL    URETHROTOMY. 


243 


allowing  a  stricture  that  lias  once  been  thoroughly  cut  to  go  for  an  entire 
week  without  dilation.  The  cut  ends  of  the  urethral  circular  muscular 
fibers  probably  retract,  and  this  serves  to  keep  the  incision  sufficiently  open 
for  all  practical  purposes.  Intermittent  dilation  by  the  urinary  outflow 
also  plays  an  important  role  in  maintaining  urethral  patency. 

Permanency  of  Result. — The  claims  of  dilating  urethrotomy  have  been 
chiefly  based  upon  permanency  of  result. 
The  only  reliable  test  in  any  particular 
case  is  re-examination  with  bulbs  some 
time  after  operation.  In  most  cases  of 
stricture  appreciable  recontraction  will 
probably  occur  within  a  very  short  time 
— a  few  months,  perhaps — after  treat- 
ment, if  at  all.  Surgeons  with  whom  the 
passage  of  an  ordinary  sound  is  a  crucial 
test  for  stricture  will,  of  course,  not  ac- 
cept this,  but  it  will  hardly  be  disputed 
by  andrologists  who  rely  upon  bulbs  for 
exploration.  Eecurrence  is  not  likely  to 
occur  if  sounding  be  persisted  in;  hence 
old-time  cases  of  urethrotomy  in  which 
the  sound  has. been  used  at  intervals  are 
no  criterions  of  the  permanency  of  the  re- 
sult in  dilating  urethrotomy.  Otis,  Mas- 
tin,  and  many  others  have  made  careful 
re-examinations  of  operated  cases  at 
variable  periods  after  operation,  and 
have  found  a  majority  still  free  from 
stricture.  As  Mastin  tersely  remarks,  "It 
is  not  the  number  of  cases,  but  the  per- 
manency of  results,  that  counts  for  the 
operation."  A  large  number  of  operated 
cases  examined  within  a  few  months  are 
not  nearly  so  valuable  as  a  few  cases  ex- 
amined several  years  after  operation. 

The  author  has  examined  a  num- 
ber of  cases  at  periods  varying  from 
one  to  twelve  years  after  internal  ure- 
throtomy,   and    has    become    convinced 

Fig.  77.- — Condition  of  urethra  fifteen  years  after  operation  of  dilating 
urethrotomy.  A,  Remains  of  fossa  navieularis  and  a  closed  false  passage 
found  at  the  time  of  operation.  B,  Small  soft  bridle.  C,  Small  soft 
cicatrix.  D,  Fine  linear  cicatrix.  E,  Depression  at  site  of  an  old  sinus. 
F,  Soft  bridles.      (After  Eldridge.) 


244  STEICTUEE    OF    THE    UEETHEA. 

that  in  the  larger  proportion  of  cases  the  operation  is  followed  by  permanent 
cure.  Cases  in  which  fresh  gonorrheal  infection  has  occurred  after  ure- 
throtomy are  apt  to  be  found  strictured,  but  such  cases  should  not  be  used 
as  an  argument  against  urethrotomy. 

ExTBENAL  Ueetheotomy.- — External  urethrotomy,  or  perineal  section, 
comprises  essentially  two  varieties  of  operation,  which,  though  involving 
the  same  structures,  differ  in  prognosis  and  facility  of  performance.  They 
are  termed  perineal  section  with,  and  perineal  section  without,  a  guide. 

Perineal  sediori  ivith  a  guide  is  the  simpler  and  safer  operation,  but 
adapted  only  to  strictures  permeable  to  instruments.  The  best  procedure 
is  Syme's  operation.  The  special  instruments  necessary  are  a  staff  with  a 
central  groove  (Fig.  80),  a  silver  catheter  of  a  caliber  of  7  or  8  English, 
a  sharp-pointed  scalpel  of  moderate  size,  and  a  strong,  broad,  grooved 
director.  The  size  of  guide  or  staff  required  necessarily  varies  according 
to  the  caliber  of  the  stricture.  Syme's  staff  has  a  shoulder  that  impinges 
upon  the  surface  of  the  stricture  anteriorly,  the  groove  on  its  convexity 
beginning  just  at  this  point.    If  false  passages  exist  a  grooved  hollow  staff 


-...■>.— -■-CTtn;^ 


^^ 


Fig.  78. — Gouley's  catheter  staff  and  guide. 

may  be  used;   the  successful  passage  of  this  instrument  into  the  bladder  is 
indicated  by  escaping  urine.     (Fig.  78.) 

Operation. — The  patient  is  anesthetized  and  put  in  the  lithotomy  posi- 
tion, with  the  feet  and  hands  fastened  together  with  lithotomy-anklets  or 
ordinary  roller  bandages  or  held  by  assistants,  and  the  staff  or  guide  passed 
into  the  bladder.  The  perineum  should  be  thoroughly  scrubbed  and.  bathed 
with  bichlorid  solution  1  to  1000.  The  operator,  seated  in  front  of  the 
patient,  now  enters  his  scalpel,  cutting  edge  upward,  into  the  perineal 
raphe  ^/a  to  ^/^  inch  in  front  of  the  anus;  an  upward  dissection  of  about 
an  inch  and  a  half  is  now  made  and  the  urethra  exposed,  when  the  knife 
is  made  to  enter  the  groove  of  the  staff  behind  the  stricture,  after  which 
the  latter  is  thoroughly  divided  from  behind  forward.  The  staff  is  now 
withdrawn,  and  a  good-sized  sound  is  passed  into  the  bladder  to  demon- 
strate that  the  canal  is  perfectly  free.  A  soft  catheter  should  now  be  passed 
into  the  bladder  and  tied  in  for  twenty-four  hours.  There  are  several  varie- 
ties of  drainage-tubes  that  are  excellent  substitutes  for  the  catheter.  The 
author  has  devised  a  hard-rubber  perineal  tube  that  has  proved  very  service- 
able.    (Fig.  82.)    At  the  end  of  from  four  or  five  days  to  a  week  gradual 


EXTERNAL   UEETHEOTOMY.  .  245 

dilation  should  be  commenced,  sounds  being  introduced  at  first  every  third 
day,  and  later  at  less  frequent  intervals.  The  urine  escapes  by  the  perineal 
wound  for  some  little  time,  but  healing  gradually  occurs  and  the  urine 
finally  flows  through  its  normal  channel.  Fistula  rarely  results;  sooner  or 
later  the  track  of  the  wound  closes  spontaneously,  incurable  fistula  being 
very  seldom  seen. 

The  rules  for  guidance  in  the  operation  as  outlined  by  Syme  are 
essentially  as  follows: — - 

1.  Be  positive  that  the  staff  or  guide  has  really  penetrated  the  stricture 
and  entered  the  bladder,  this  caution  being  especially  necessary  if  false 
passages  exist. 


r 


J 


Fig.  79. — Filiform  bougies. 

2.  Take  care  not  to  deviate  the  incision  from  the  median  line.  In  this 
location  a  sort  of  septum  exists  even  in  the  deep  perineal  tissues.  So  long 
as  the  incision  does  not  deviate  from  this  line  there  is  little  or  no  danger 
of  injuring  any  vessel  of  considerable  size.  The  principal  vessel  that  is 
in  danger  is  the  artery  of  the  bulb;  but  this  need  not  be  cut,  as  a  rule,  if 
the  incision  is  carefully  made  in  the  raphe. 

3.  Keep  the  edge  of  the  knife  mainly  upward  to  avoid  opening  the 
posterior  layer  of  the  deep  fascia  of  the  perineum,  with  consequent  danger 
of  infiltration  of  urine  into  the  pelvis,  with  serious  inflammation  and  per- 
haps gangrene  of  cellular  tissue. 


.«=imv»«l333Jl 


Fig.  80.— Tunneled  sound. 

4.  Insert  the  point  of  the  knife  posterior  to  the  stricture,  and  incise 
it  by  cutting  from  behind  forward  in  the  groove  of  the  guide.  (This  is  not 
always  practicable.) 

5.  There  is  sometimes  considerable  trouble  in  passing  an  instrument 
into  the  bladder  after  the  stricture  has  been  cut.  This  may  be  obviated  by 
inserting  a  director  with  a  broad  groove  into  the  posterior  portion  of  the 
urethra  after  the  stricture  has  been  divided  and  before  the  withdrawal  of 
the  staff.  The  grooved  director  is  turned  upward  in  such  a  manner  that 
as  the  sound  or  catheter  is  passed  through  the  canal  its  point  is  directed 
past  the  incision  into  the  bladder. 

In  cases  in  which  it  is  difficult  to  insert  the  ordinary  grooved  staff  a 


246 


STEICTUEE    OF    THE    UEETHRA. 


filiform  bougie  (Fig.  79)  may  be  passed  into  the  bladder  and  Thompson's 
dilator  threaded  upon  it.  With  this  the  stricture  is  expanded  until  it  will 
readily  admit  the  staff.  A  tunneled  staff  may,  however,  be  used,  being 
forced  into  the  bladder  over  the  bougie  as  a  guide. 

Perineal  section  u-itliout  a  guide  is  a  most  troublesome  and  formidable 
operation.  Skilled  surgeons  have  attempted  the  operation  and  failed. 
Others  have  succeeded  only  after  a  bunglesome,  tedious,  and  prolonged 
search  for  the  urethra.  It  is  a  very  fortunate  circumstance  that  such  opera- 
tions are  rarely  necessary,  for  if  the  surgeon  is  patient  and  administers  an 
anesthetic  he  will  usually  succeed  in  passing  an  instrument  through  the 
stricture  sooner  or  later,     ^o  matter  how  small  the  instrument  may  be,  it 


Fig.  81. — Deep  urethrotomy.     (After  Wheelhouse.) 


is  an  accurate  guide  to  the  course  of  the  urethra.  Once  an  instrument  is 
passed  into  the  bladder,  the  case  is  practically  under  control.  A  tunneled 
staff  can  be  threaded  over  a  filiform  bougie  and  pushed  through  the  stricture, 
the  operation  being  then  completed  as  in  simple  perineal  section. 

The  practicability  of  instrumentation,  therefore,  determines  the  safety 
of  perineal  urethrotomy. 

In  considering  perineal  section  without  a  guide  we  must  admit  that, 
although  rare,  cases  of  practically  impassable  stricture  are  encountered. 
These  may  be  termed  surgically  impermeable.  Complete  obliteration  of 
the  urethra  can  only  be  produced  by  injury  or  sloughing  from  some  cause. 
Even  where  fistulas  co-exist  with  old  indurated  stricture  the  urethra  is  rarely 
impervious  to  either  instruments  or  urine.    It  is  conceivable,  however,  that 


EXTERNAL    UEETHEOTOMY.  247 

it  may  become  so  as  a  result  of  diversion  of  the  urine  from  its  normal 
channel  by  a  fistula^  providing  there  is  an  exudate-producing  lesion  of  the 
mucous  membrane. 

It  is  nothing  unusual  for  the  surgeon  to  discover  while  preparing  for 
perineal  section  that  anesthesia  has  relaxed  the  parts,  so  that  an  instrument 
of  moderate  size  may  be  readily  introduced.  Whenever,  therefore,  a  radical 
operation  is  determined  upon,  an  attempt  should  be  made  to  pass  instru- 
ments under  anesthesia,  in  the  hope  of  either  providing  a  guide  for  opera- 
tion or  paving  the  way  to  treatment  by  dilation.  As  a  rule,  a  stricture 
permeable  to  fluid  is  permeable  to  bougies.  It  must  be  acknowledged,  how- 
ever, that  there  are  occasional  exceptions  in  which  the  urethra  has  become 
so  tortuous  and  contracted,  and  the  tissues  of  the  perineum  so  indurated 
by  inflammatory  deposit — perhaps  occurring  as  a  consequence  of  extrava- 
sation of  urine — that  no  instrument  can  be  passed,  although  urination  is 
comparatively  free.  In  such  cases  perineal  section  without  a  guide  is  neces- 
sary. 


Fig.  82. — Author's  perineal  drainage-tube. 

Operations  begun  without  a  grooved  guide  or  bougie  to  indicate  the 
course  of  the  urethra  may  often  be  completed  with  a  guide  after  the  ante- 
rior surface  of  tbe  stricture  has  been  exposed,  a  filiform  bougie  being  then 
passed. 

Operation. — There  are  two  ways  of  performing  perineal  section  with- 
out a  guide:  1.  The  urethra  is  opened  in  front  and  the  stricture  divided 
from  before  backward.  2.  The  urethra  is  opened  posteriorly  and  the  strict- 
ure divided  from  behind  forward.  The  first  method  is  preferable.  A  good- 
sized  sound  should  be  passed  down  to  the  stricture.  It  is  then  turned  so 
that  its  point  projects  in  the  perineum.  An  incision  aboiit  an  inch  and  a 
half  long  is  now  made  upon  it  and  the  urethra  exposed.  A  small  opening 
is  then  made  in  the  canal  just  in  front  of  the  stricture,  and  the  sound  hooked 
up  into  the  angle  of  the  wound.  A  ligature  is  passed  on  each  side  of  the 
incision,  and  given  to  an  assistant.  These,  in  conjunction  with  the  hook- 
like action  of  the  staff,  hold  the  edges  of  the  wound  apart  and  facilitate  in- 
spection and   exploration   of  the   stricture.      After  hemorrhage   has   been 


248  STKICTUEE    OF   THE   UKETHRA. 

checked  the  opening  through  the  stricture  may  often  be  readily  seen.  A 
tine  probe  or  small  director  is  slipped  into  this  if  possible,  and  a  fine-bladed 
tenotome  passed  along  the  guide,  dividing  the  stricture.  Great  pains  should 
be  taken  to  find  the  orifice  of  the  stricture,  for,  if  a  filiform  bougie  can  be 
passed  through  it,  the  operation  is  greatly  simplified,  the  chief  danger  of 
the  operation  being  that  the  surgeon  will  lose  the  urethra,  and  in  his  aimless 
efforts  to  find  it  produce  severe  or  even  fatal  hemorrhage.  The  author  re- 
calls such  a  case,  operated  by  a  very  capable  surgeon,  in  which  there  was 
so  much  hemorrhage  that  the  patient  died  within  a  few  hours. 

Should  it  be  impossible  to  pass  a  guide  after  the  face  of  the  stricture 
has  been  exposed,  the  urethra  may  be  opened  up  posteriorily  and  an  at- 
tempt made  to  pass  a  probe  or  bougie  from  behind  forward.  Failing  in 
this,  a  dissection  from  before  backward  in  the  normal  direction  of  the 
urethra  is  necessary.  In  difficult  cases  of  this  kind  the  author  inclines  to 
suprapubic  section  and  retrograde  catheterism.    This  procedure  has  proved 


Fig.  83. — Shirted  cannula. 

very  useful  on  several  occasions.  Suprapubic  section  is  safer  than  a  pro- 
longed search  for  the  urethra. 

After  the  stricture  has  been  divided  a  full-sized  sound  should  be  passed 
into  the  bladder  to  demonstrate  that  the  passage  is  clear.  The  sound  is  then 
removed,  and  a  catheter  or  tube  passed  via  the  perineal  wound.  This  is 
tied  in  and  allowed  to  drain  into  the  urinal.  It  may  be  removed  in  two  or 
three  days.  Such  a  drainage-tube  facilitates  washing  the  bladder  and  the 
perineal  wound  with  antiseptic  solutions  and  prevents  infection. 

The  sound  should  be  passed  at  proper  intervals,  as  after  the  ordinary 
perineal  operation. 

Hemorrhage  after  perineal  section  may  usually  be  controlled  by  press- 
ure.   If  venous  oozing  be  free,  the  wound  may  be  plugged  with  styptic  cot- 


COMPLICATIONS    AND   RESULTS    OF    STRICTURE.  249 

ton,  or  cotton  saturated  with  spirit  of  turpentine.  Irrigation  with,  very  hot 
water  is  often  efficacious.  When  bleeding  is  obstinate  a  petticoated  or 
"shirted"  cannula  (Fig.  83)  may  be  introduced,  as  in  lithotomy.  In  one 
case  the  author  found  the  following  device  to  act  very  well:  A  stifE  gum 
catheter  was  passed  through  an  ordinary  condom  and  into  the  bladder. 
The  condom  was  then  blown  up  by  a  small  catheter  introduced  into  the  outer 
end,  and  tied  firmly  about  the  catheter  left  in  the  bladder,  so  as  to  prevent 
the  air's  escaping.  By  this  device  sufficient  pressure  was  secured  to  stop 
the  hemorrhage.     A  perineal  crutch  may  become  necessary. 

One  word  of  caution  to  the  operator  may  not  be  untimely.  He  should 
begin  his  operation,  if  possible,  early  in  the  day,  and  be  sure  and  secure 
plenty  of  light.  A  dark  day  and  a  hurry  have  been  fatal  to  not  a  few  pa- 
tients in  the  practice  of  difEerent  surgeons. 

COMPLICATIONS    AND    RESULTS    OF    STRICTURE. 

False  Passages. — False  passages  are  rare  in  the  practice  of  surgeons 
who  exhibit  the  necessary  patience  and  gentleness  in  instrumentation.  They 
are  rarely  caused  by  the  use  of  large  instruments  in  ordinary  dilation,  and 
are  very  exceptionally  produced  by  other  than  metallic  instruments. 

Forcible  instrumentation  was  formerly  occasionally  practiced  for  the 
relief  of  retention.  A  catheter  was  passed  down  to  the  stricture  and  forcibly 
crowded  toward  the  bladder.  Very  rarely  indeed  did  the  instrument  pass 
through  the  stricture.  More  often  it  was  forced  entirely  through  the  ure- 
thral walls  into  the  cellular  tissue.  Once  in  awhile  the  operator  succeeded 
in  reaching  and  evacuating  the  bladder.  The  almost  inevitable  result  of 
such  surgery  was  the  frequent  occurrence  of  false  passages.  When  an  in- 
strument is  thus  passed  it  may  enter  an  enlarged  urethral  follicle  and  pro- 
duce rupture  at  that  point.  More  frequently  the  instrument  enters  a  pocket 
in  the  face  of  the  stricture,  the  false  passage  beginning  at  this  point.  The 
signs  indicating  this  accident  have  already  been  enumerated. 

Treatment. — When  the  surgeon  realizes  that  a  false  passage  has  been 
made,  he  should  let  the  urethra  severely  alone  for  several  weeks  unless 
retention  exists.  Further  instrumentation  will  in  all  probability  result  in 
a  chronic  induration  of  the  false  passage.  There  is  at  first  slight  hemor- 
rhage, and  within  a  few  days  more  or  less  purulent  discharge.  As  a  rule, 
the  false  passage  closes  within  two  or  three  weeks.  It  may,  however,  in 
spite  of  conservatism,  become  chronic.  Such  accidents  as  urinary  fever, 
infiltration  of  urine,  abscess,  and  fistula  are  occasional  results. 

In  exploring  a  canal  in  which  a  false  passage  is  known  to  exist  great 
care  should  be  taken  to  avoid  penetrating  it.  The  oftener  such  a  passage 
is  dilated  the  longer  will  it  persist;  it  may  become  incurable.  The  devia- 
tion of  the  instrument,  the  sensation  imparted  to  the  hand,  and  the  pa- 
tient's subjective  sensations  usually  indicate  the  position  of  the  sound. 
Careful  study  is  necessary  to  determine  the  location  of  orifices  of  old  false 


250  STRICTURE    OF    THE    URETHRA. 

jjassages.  As  a  rule,  the  instrument  engages  in  the  orifice  of  a  false  passage 
more  easily  than  in  the  stricture,  and  the  comparative  facility  with  which 
the  instrument  is  passed  into  an  abnormal  channel  may  mislead  the  sur- 
geon into  the  notion  that  he  is  dilating  the  stricture.  A  false  passage  may 
sometimes  be  avoided  when  its  location  has  been  determined.  It  may  be 
necessary,  when  an  instrument  has  once  been  passed,  to  allow  it  to  remain 
in  situ,  other  and  finer  instruments  being  passed  in  the  hope  of  engaging 
one  in  the  orifice  of  the  stricture  proper.  The  expedient  of  filling  the  ure- 
thra with  filiform  bougies  is  sometimes  successful,  one  or  more  instruments 
finally  j^assing  the  stricture.  An  excellent  plan  is  to  pass  an  endoscopic 
tube  down  to  the  face  of  the  stricture,  a  filiform  being  passed  through  it 
and  an  attempt  made  to  enter  the  proper  channel;  if  necessary  the  tube 
may  be  filled  with  filiforms.  When  once  an  instrument  is  passed  through 
the  stricture  it  should  be  alloAved  to  remain  in  situ,  and  the  stricture  either 
dilated  to  a  moderate  extent  by  a  Thompson  dilator  slipped  along  a  filiform 
guide  or  treatment  by  continuous  dilation  begun.  If  it  is  found  impos- 
sible to  pass  instruments  and  retention  exists,  an  aspirator  or  trocar  may  be 
used,  while  attempts  at  instrumentation  are  still  persisted  in. 

The  best  operation  for  stricture  complicated  by  false  passages  is  peri- 
neal section.  Should  it  be  impossible  to  introduce  a  guide,  it  is  necessary 
to  operate  without  it. 

Eetextiox  of  Urixe. — Eetention  of  urine  is  the  most  frequent 
complication  of  stricture.  In  all  strictures  of  small  caliber  the  patient  is 
constantly  in  danger  of  ^Dractically  complete  closure  of  the  urethra  from 
spasm,  or  congestive  and  inflammator}-  infiltration — i.e.,  plus  conditions 
— at  the  site  of  the  lesion.  The  liability  to  this  accident  is  greatly  modified 
by  the  patient's  constitutional  condition,  his  habits,  and,  what  is  quite  as 
important,  the  delicacy  of  the  manipulations  instituted  for  the  cure  of  the 
disease.  Chilling  of  the  feet  and  legs,  indulgence  in  alcoholics  even  to  a 
moderate  extent,  overeating,  and  sexual  excitement  with  or  without  grat- 
ification are  the  most  frequent  exciting  causes. 

When  retention  of  urine  becomes  complete  the  bladder  soon  becomes 
distended  to  its  utmost  capacity,  and  perhaps  yields  to  the  pressure  of  the 
contained  fluid  until  it  fills  a  large  portion  of  the  abdomen;  as  a  result  of  this 
distension  there  is  considerable  "pain  and  constitutional  disturbance.  It  now 
becomes  urgently  necessary  to  speedily  evacuate  the  bladder.  If  this  be  not 
done,  overfiow  may  occur  after  a  time  or  the  urethra  will  yield  posterior 
to  the  stricture,  with  extravasation  of  urine  either  in  front  or  behind  the 
triangular  ligament.  Gangrene  of  the  cellular  tissue,  with  profound  pros- 
tration, a  typhoid  condition,  and  usually  death,  will  ensue  if  the  extravasa- 
tion be  extensive;  in  more  fortunate  cases  an  abscess  may  form  that  sub- 
sequently discharges  and  leaves  a  fistula.  In  long-standing  cases  where 
the  bladder  is  dilated  and  sacculated  the  bladder  itself  may  possibly  rupt- 
ure, with  an  inevitably  fatal  result.     After  an   attack   of  retention  the 


COMPLICATIONS    AXD    EESULTS    OF    STKICTUEE.  251 

bladder  is  always  left  in  a  much  worse  condition  than  before,  and  perhaps 
may  be  left  in  a  more  or  less  acutely-inflamed  state. 

Treatment. — It  is  well  to  avoid  instrumentation  at  this  time  if  possible, 
as  the  contact  of  a  catheter  with  the  inflamed  structures  is  apt  to  increase 
the  irritation.  Antispasmodics  and  a  full  hot  bath  should  be  given.  Mor- 
phia may  be  given  by  the  mouth  or  hypodermically  until  its  full  narcotic 
effect  results.  Should  these  measures  fail,  an  attempt  should  be  made  to 
pass  a  small  catheter.  Contrary  to  what  might  be  expected,  an  instrument 
sometimes  passes  through  a  stricture  more  easily  where  retention  exists  than 
under  other  circumstances.  This  is  probably  because  slight  absorption  of 
the  stricture-tissue  occurs  as  a  consequence  of  inflammation.  In  addition, 
it  is  probable  that  the  pressure  behind  the  obstruction  serves  to  stretch  the 
stricture  slightly,  thus  facilitating  the  entrance  of  an  instrument.  If  neces- 
sary an  anesthetic  should  be  given.  The  surgeon  should  never  despair  of 
being  able  to  introduce  a  catheter  until  he  has  failed  with  the  patient  under 
an  anesthetic.  If  a  catheter  cannot  be  introduced  primarily,  a  filiform 
bougie  may  possibly  be  passed.  This  should  be  left  in  the  bladder  for  some 
little  time,  and  if  when  it  is  withdrawn  the  urine  does  not  flow,  as  it  is  very 
apt  to  do,  a  small  catheter  may  usually  be  introduced.  When  once  an  instru- 
ment has  been  passed  the  case  is  under  control.  The  instrument  should  be 
tied  in  the  bladder.    Leeches  may  now  be  applied  to  the  perineum. 

Free  saline  catharsis  usually  benefits  in  a  derivative  manner.  Deriva- 
tion may  also  be  produced  by  the  hypodermic  injection  of  pilocarpin. 

Should  it  be  impossible  to  relieve  the  retention  via  the  urethra,  it  is 
usually  wise  to  temporize  by  the  employment  of  an  aspirator  in  preference 
to  radical  operations.  In  most  cases  the  urine  flows  by  the  natural  chan- 
nel shortly  after  vesical  distension  has  been  relieved  by  the  aspirator. 
Should  this  not  occur,  however,  the  aspirator  may  be  again  used  a  number 
of  times,  if  necessary,  the  surgeon  meanwhile  proceeding  with  antiphlo- 
gistic and  derivative  measures  and  cautious  and  gentle  attempts  to  pass 
an  instrument. 

Should  the  surgeon  be  unable  to  see  the  patient  frequently,  it  is  well, 
after  the  introduction  of  a  filiform  bougie  or  small  catheter,  to  pass  a  tun- 
neled Thompson  dilator  over  it  as  a  guide,  and  stretch  the  stricture  mod- 
erately. Divulsion  and  internal  urethrotomy  are  not  to  be  recommended  at 
this  time,  as  a  rule.  The  passage  of  a  catheter  for  the  relief  of  retention 
should  usually  be  considered  as  the  commencement  of  treatment  by  con- 
tinuous dilation.  When  other  means  fail  perineal  section  without  a  guide 
should  be  performed. 

Infilteatiox  of  Urine. — Infiltration  of  urine  is  the  most  serious 
complication  of  stricture.     It  may  be  produced  by: — 

1.  Eupture  of  urethra  or  bladder  from  prolonged  retention. 

2.  Eupture  of  the  dilated  and  ulcerated  urethra  behind  the  obstruc- 
tion, from  straining  efforts  at  micturition. 


253  STEICTUEE    OF    THE    UKETHRA. 

3.  Laceration  of  the  urethra  due  to  overdistension  by  large  sounds. 
In  this  instance  infiltration  occurs  at  the  next  act  of  urination. 

4.  Division  or  rupture  of  the  urethra  in  internal  urethrotomy  or  divul- 
sion. 

5.  Burrowing  of  urine  betAveen  the  layers  of  tissue  about  the  wound  in 
perineal  section. 

Infiltration  occurs  in  three  forms:  (a)  Extravasation  of  urine  into  the 
pelvic  cellular  tissue  from  rupture  of  a  dilated,  thinned,  and  sacculated 
bladder,  (b)  Eupture  of  the  urethra  within  the  confines  of  the  deep  layer 
of  the  superficial  fascia  of  the  perineum  or  Buck^s  fascia,  (c)  Infiltration 
produced  by  rupture  behind  the  triangular  ligament  or  deep  perineal  fascia. 

The  most  common  method  of  extravasation  is  due  to  rupture  of  the 
urethra  immediately  behind  the  stricture.  This  structure,  already  thinned 
and  dilated,  becomes  overdistended,  and  eventually  ulceration  occurs,  usu- 
ally upon  the  floor  of  the  canal.  As  a  consequence  of  retention  or  straining 
in  micturition  a  few  drops  of  urine  escape  into  the  surrounding  cellular 
tissue,  and  extension  of  the  ulcerative  process  immediately  begins,  with 
perhaps  more  or  less  sloughing.  As  a  consequence,  the  trifling  aperture  in 
the  urethral  floor  becomes  enlarged,  and  in  a  short  time  the  urine  escapes 
in  considerable  quantity  into  the  cellular  tissue  of  the  scrotum,  perineum, 
groin,  and,  if  Buck's  fascia  gives  way,  the  thighs.  In  some  instances  a 
dilated  urethral  follicle  becomes  acutely  inflamed,  as  a  consequence  of  which 
its  duct  becomes  occluded.  Within  the  follicle  a  drop  of  urine  is  retained 
in  conjunction  with  the  products  of  decomposition  and  inflammation,  dis- 
tending the  little  pseudocyst.  Under  these  circumstances  it  is  apt  to  give 
way,  either  into  the  urethra  or  externally.  Should  it  give  way  externally, 
extravasation  of  urine  may  not  occur,  the  process  remaining  as  a  folliculitis 
or,  if  more  extensive,  a  urethral  phlegmon.  The  resultant  abscess  may  be 
quite  extensive.  If  the  contents  of  the  follicle  escape  into  the  urethra,  an 
opening  is  afforded  for  the  entrance  of  urine.  Later  on  the  follicle  ruptures 
from  overdistension,  and  abscess  occurs.  Fistula  may  result.  In  some  in- 
stances the  abscess  flrst  ruptures  externally  and  subsequently  into  the  ure- 
thra. Under  such  circumstances  serious  extravasation  is  not  apt  to  occur,  the 
entire  extent  of  the  fistula  having  become  lined  with  pseudomembrane  that 
protects  the  tissues  from  burrowing  urine.  In  other  instances  rupture 
of  the  urethra  occurs,  with  the  formation  of  abscess  or  sloughing,  the  process 
finally  appearing  externally  and  a  fistulous  opening  into  the  urethra  being 
thus  established.  The  slower  the  infiltration,  the  more  apt  it  is  to  be  con- 
fined by  inflammatory  exudate,  which  acts  conservatively  by  preventing 
serious  inflltration. 

The  slighter  forms  of  infiltration  may  occur  anywhere  in  the  urethra 
and  produce  folliculitis,  periurethral  phlegmon,  abscess,  and  fistula.  Wlien 
extensive  extravasation  of  urine  occurs,  the  portion  of  the  canal  that  usually 
gives  way  is  the  membranous  urethra,  between  the  layers  of  the  triangular 


COMPLICATIONS    AND    RESULTS    OF    STEICTURE.  253 

ligament.  Here  the  wall  of  the  canal  is  rather  weak,  because  of  lack  of 
support  by  the  surrounding  tissues.  It  is  here  also  that  dilation  and 
thinning  are  most  apt  to  exist,  severe  stricture  being  most  frequently  situ- 
ated at  the  bulbo-membranous  junction.  Strictures  anterior  to  this  point 
are  more  often  of  comparatively  large  caliber,  and  are  not  apt  to  develop 
the  conditions  that  predispose  to  or  excite  serious  extravasation.  The 
infiltrated  urine  finds  its  way  after  a  time  through  the  anterior  layer 
of  the  triangular  ligament  at  the  point  where  it  is  penetrated  by  the 
urethra.  It  is  now  beneath  the  deep  layer  of  the  superficial  fascia  of  the 
perineum — i.e.,  within  the  confines  of  Buck's  fascia — which,  if  it  remains 
intact,  subsequently  guides  the  course  of  the  urine.  This  structure,  it  will 
be  remembered,  is  attached  to  the  anterior  layer  of  the  triangular  ligament 
in  the  perineum,  and  laterally  to  the  rami  of  the  ischia  and  pubes  as  far 
upward  as  the  pubic  spine,  where  it  becomes  continuous  with  the  deep 
layer  of  the  superficial  fascia  of  the  abdomen.  This  latter  fascia  in  its  turn 
is  attached  anteriorly  along  Poupart's  ligament  as  far  as  the  crest  of  the 
ilium.  The  infiltrated  fluid,  therefore,  invariably  takes  a  direction,  first, 
forward  into  the  perineum  and  scrotum,  and,  second,  upward  upon  the 
genitalia  and  the  anterior  abdominal  wall  and  outward  along  the  groin  upon 
either  side.  Were  it  not  for  this  limitation  of  extravasation  the  fluid  would 
be  governed  by  gravity,  and  would  pass  backward  and  downward,  extrava- 
sating  about  the  rectum  and  down  the  thighs.  When  Buck^s  fascia  gives 
way,  the  infiltrated  urine  takes  this  course. 

The  effects  of  infiltration  are  general  and  local.  The  general  symptoms 
are,  from  the  first,  in  some  instances,  asthenic  and  irritative.  Even  in  the 
strongest  patients  extensive  infiltration  is  likely  to  be  soon  succeeded  by 
asthenia  with  typhoid  symptoms;  low,  muttering  delirium;  dry,  brown 
tongue;  sordes,  and  finally  coma  and  death.  If  treatment  is  unsuccessful 
in  relieving  cases  of  limited  infiltration,  abscess  results,  with  the  symptoms 
observed  under  ordinary  circumstances,  with  perhaps  more  marked  pros- 
tration. 

The  local  effects  of  infiltration  are  very  marked.  The  results  are  not 
those  of  contact  of  urine  per  se,  but  of  urine  vitiated  by  decomposition  and 
the  products  of  inflammation.  Healthy  urine  is  harmless  when  injected 
into  the  cellular  tissue. 

When  urine  is  infiltrated  into  the  perineum  and  about  the  genitals  the 
effect  of  the  irritant  poison  is  immediately  manifest  wherever  the  areolar 
tissue  is  touched  by  the  fiuid.  A  diffuse  cellulitis  is  set  up,  the  tissues  being 
converted  into  dark,  pultaceous,  stringy  sloughs,  mingled  with  dark  fetid 
pus  and  decomposing  ammoniacal  urine.  If  the  urethra  gives  way  sud- 
denly, the  irritant  fluid  is  forced  into  the  tissues  for  some  distance.  Under 
these  circumstances  tissue-destruction  is  very  extensive.  The  scrotum  may 
slough,  baring  the  testes.  The  patient  is  likely  to  die  before  this  occurs, 
however;    so  that  the  condition  is  rare.     Extravasation  sometimes  occurs 


254  STEICTUEE    OF    THE    UEETHRA. 

more  slowly,  as  alread}'  indicated.  A  few  drojis  of  the  irritant  fluid  escape 
from  the  canal  through  a  slight  solution  of  continuity  in  its  coats;  this 
gives  rise  to  phlegmonous  inflammation  about  the  urethra  that  limits  for 
a  certain  time,  perhaps  indefinitely,  progression  of  the  extravasated  fluid. 
This  inflammation  usually  develops  abscess  that  may  break  internally  or 
externally  followed  by  general  extravasation  or  fistula.  AVhen  extravasation 
is  rapid  and  extensive  the  perineum  becomes  brawny,  and  finally  boggy,  the 
scrotum  distended  and  edematous,  and  the  parts  dusky  or  purplish  red,  the 
tissues  speedily  becoming  gangrenous. 

If  the  patient  resists  the  depressing  effects  of  the  resulting  destruction 
of  tissue,  repair  may  be  very  rapid.  The  reparative  power  of  the  tissues 
involved  is  something  remarkable,  and  is  noted  not  only  in  these  cases,  but 
in  phlegmonous  erysipelas  and  cellulitis  affecting  this  region.  The  extrava- 
sation rarely  extends  farther  than  the  groins  and  lower  part  of  the  abdom- 
inal wall,  but  has  been  known  to  reach  the  level  of  the  ribs. 

When  in  retention  the  urethra  ruptures  between  the  layers  of  the  tri- 
angular ligament,  a  sense  of  relief  is  experienced  by  the  patient,  with  a  feel- 
ing as  though  the  tissues  had  ruptured  in  the  perineum,  and  perhaps  more 
or  less  pain.  The  sj-mptoms  may  be  obscure  for  some  little  time,  and  very 
little  swelling  may  occur,  but  in  a  few  hours,  or  perhaps  not  for  a  day  or 
two,  a  sense  of  heat,  throbbing,  or  lancinating  perineal  pain  and  burning 
will  be  experienced;  later  on,  a  boggy,  diffuse,  purplish-red  swelling  appears 
in  the  perineum  and  scrotum  and  rapidly  extends  forward. 

When  infiltration  takes  place  entirely  behind  the  triangular  ligament, 
there  is  a  similar  sense  of  relief,  but  the  subsequent  symptoms  are  even 
more  obscure.  After  a  time,  if  the  patient  survives,  deep,  throbbing  pain 
develops,  with  perhaps  swelling  of  the  perineum.  Examination  per  rectum 
may  detect  the  boggy  fluctuation  characteristic  of  infiltration.  In  cases  of 
rupture  posterior  to  the  ligament  the  fluid  is  likely  to  burrow  into  the  pelvis 
and  about  the  rectum  and  prostate  and  destroy  life  without  any  positive 
external  manifestations. 

Inflltration  from  vesical  rupture  is  one  of  the  rarest  forms  of  this  com- 
plication of  stricture.  Its  method  of  production  and  effects,  although  more 
obscure,  are  almost  identic  with  inflltration  from  urethral  rupture.  If 
the  bladder  be  fairly  healthy,  retention  of  urine  is  not  likely  to  produce 
rupture  unless  traumatism  be  superadded.  A  fall  or  blow  upon  the  ab- 
domen may  produce  it  under  such  circumstances.  Eelief  is  usually  afforded 
by  rupture  of  the  portion  of  the  genito-urinary  tract  that  offers  least  re- 
sistance— i.e.,  the  dilated  diseased  urethra  behind  the  stricture — or  by  over- 
flow. A  certain  amount  of  urine  may  escape  by  distension  of  the  diseased 
portion  of  the  urethra,  although  the  bladder  cannot  empty  itself.  In  some 
cases  overflow  occurs  from  subsidence  of  the  inflammatory  and  spasmodic 
elements  of  the  obstruction.  By  this  time,  however,  the  bladder  has  become 
so  atonied  by  overdistension  that  it  cannot  empty  itself.     When  the  blad- 


COMPLICATIOXS   AXD    EESULTS    OF    STEICTUEE.  255 

der  is  ulcerated,  as  it  may  be  when  calculus  complicates  stricture  or  if  an 
instrument  has  been  allowed  to  remain  long  in  contact  with  the  vesical 
walls,  the  bladder  may  yield  at  the  weakened  point.  In  cases  of  extreme 
vesical  dilation  and  sacculation  the  walls  of  the  viscus  are  apt  to  yield  to 
the  pressure  of  the  urine  at  the  point  of  least  resistance;  i.e.,  the  thinnest, 
and  usually  the  largest,  sacculus.  When  vesical  rupture  occurs  the  urine 
escapes  into  the  peritoneal  cavity. 

Treatment. — The  treatment  of  infiltration  must  be  prompt  and  ener- 
getic. When  symptoms  indicating  rupture  of  the  urethra  develop,  perineal 
urethrotomy  should  be  performed  immediately.  Vesical  drainage  should 
be  provided  for  by  the  insertion  of  a  large  rubber  tube  through  the  wound. 
Thorough  antisepsis  by  irrigations  with  weak  solutions  of  mercury  bichlorid 
should  be  at  once  established.  If  difEuse  swelling  of  the  perineum,  scrotum, 
penis,  thighs,  or  groins  exists,  each  prominent  point  should  be  freely  incised. 

Whenever  lancinating  and  throbbing  pain  with  more  or  less  circum- 
scribed swelling  occurs  in  the  perineum,  whether  the  scrotum  be  involved 
or  not,  perineal  section  should  be  performed.  Eectal  examination  some- 
times reveals  extravasated  fluid  where  the  symptoms  are  otherwise  obscure. 
Under  such  circumstances  the  perineum  should  be  opened  medially,  and  a 
deep  incision  made  in  the  direction  of  the  perirectal  infiltration,  the  left 
index  finger  being  passed  well  up  into  the  rectum  to  protect  the  gut  from 
injury. 

The  only  hope  of  saving  life  in  cases  of  extensive  extravasation  is  free 
incision  of  all  points  where  the  infiltrated  fluid  can  be  reached.  Even  if 
extravasation  and  subsequent  cellulitis  and  sloughing  be  severe,  a  favorable 
result  may  often  be  secured  by  this  radical  measure.  It  is  not  sufficient  to 
liberate  fluid  that  has  already  escaped;  it  is  necessary  to  prevent  further 
extravasation  by  section  of  the  stricture  and  perineal  drainage. 

Having  obtained  an  outlet  for  the  morbid  urine,  sloughs,  and  in- 
flammatory products  of  extravasation,  some  antiseptic  dressing  should  be 
applied  that  will  not  only  keep  the  parts  aseptic,  but  also  conserve  the 
vitality  of  the  cellular  tissue.  Both  indications  may  be  met  by  hot  poultices 
of  equal  parts  of  charcoal  and  linseedmeal,  sprinkled  liberally  with  brewers' 
yeast  or  hot  sublimate  solution.  All  sloughs  should  be  removed  as  soon  as 
loosened,  and  the  parts  irrigated  frequently  to  remove  discharge  as  fast  as 
formed.  As  the  sloughs  separate  free  purulent  discharge  begins,  causing  a 
severe  drain  upon  the  already  depleted  system.  Liberal  support,  dietetic  and 
medicinal,  is  required.  Milk-punch,  eggnog,  large  quantities  of  milk,  and 
concentrated  broths  should  constitute  the  diet.  A  liberal  quantity  of  stimu- 
lants, either  brandy,  whisky,  or  the  heavier  wines  should  be  administered. 
Should  the  patient's  stomach  be  irritable,  champagne  is  useful.  Digitalis, 
carbonate  of  ammonia,  quinin,  and  tincture  of  the  chlorid  of  iron  are  the 
only  reliable  remedies  against  asthenia  in  these  cases,  and  should  be  given 
freely. 


256  STEICTUKE    OF    THE   UEETHEA. 

EuPTUEE  OF  THE  Bladdee. — This  condition  incidental  to  stricture  de- 
mands the  same  treatment  as  under  other  circumstances,  but  is  almost 
inevitably  fatal. 

Peeiueetheal  abscess  is  intimately  associated  with  extravasation. 
The  latter  may  be  of  comparatively  trifling  importance  per  se,  the  collection 
of  pus  being  relatively  more  serious.  Abscess  about  the  urethra  may  arise 
from  several  causes:  1.  The  escape  of  a  drop  or  two  of  toxic  urine  into  the 
cellular  tissue  from  solution  of  continuity  of  the  urethral  walls.  2.  The 
escape  of  a  few  drops  of  urine  into  a  dilated  follicle  with  subsequent  free 
suppuration  and  rupture  of  the  latter.  3.  Inflammation  of  follicles  due  to 
the  passage  of  instruments.  4.  Puncture  or  rupture  of  the  urethral  walls 
by  instruments.  5.  Phlegmonous  inflammation  from  absorption  of  organic 
poison  by  the  lymphatics  from  behind  the  stricture;  this  poisonous  mate- 
rial, coming  in  contact  with  the  cellular  tissue,  sets  up  suppurative  inflam- 
mation. 

Periurethral  abscess  bears  a  distinct  relation  to  periurethral  phlegmon 
and  folliculitis.  When  decomposing  urine  escapes  into  the  periurethral 
areolar  tissue,  it  sets  up  inflammation  attended  by  plastic  exudate;  in  some 
instances  the  exudative  material  closes  the  orifice  through  which  the  urine 
escapes  and  prevents  further  extravasation,  thus  circumscribing  the  abscess. 
Abscess  of  this  kind  may  occur  about  any  portion  of  the  urethra,  generally 
in  the  perineal  part  of  the  canal  because  of  its  frequent  association  with 
bulbo-membranous  stricture.  It  may  subsequently  lead  to  extravasation, 
because  of  its  opening  into  the  urethra,  thus  permitting  the  escape  of  the 
urine  into  its  cavity,  the  walls  of  which  subsequently  yield,  or  it  may  bur- 
row to  the  surface  externally  and  heal  without  difficulty.  Again,  it  may 
open  internally  and  burrow  externally  without  extensive  extravasation,  the 
track  of  the  pus  being  limited  by  plastic  deposit.  Under  these  circum- 
stances fistula  results.  These  abscesses  are  rarely  dangerous  per  se,  their 
importance  being  chiefly  due  to  the  danger  of  general  extravasation  and  the 
formation  of  urinary  fistulas. 

The  amount  of  mischief  done  by  urinary  abscess  depends  greatly  on 
its  situation.  When,  as  usually  happens,  it  forms  beneath  the  floor  of  the 
canal,  it  readily  comes  forward  without  extensive  burrowing;  but  when 
situated  on  the  roof  (which  is  very  rare)  or  at  the  upper  part  of  the  side 
of  the  canal,  it  may  burrow  extensively  before  it  points,  occasioning  great 
induration,  infiltration,  and  destruction  of  tissue  in  neighboring  parts. 

Symptoms. — Periurethral  abscess  appears  as  a  small,  circumscribed, 
tender,  painful,  and  hard  tumor  somewhere  in  the  course  of  the  urethra. 
There  is  usually  little  or  no  constitutional  reaction.  Sometimes,  however, 
in  extensive  abscesses  more  or  less  fever  is  noticeable.  When  located  in  the 
perineum  this  part  may  become  tense,  hard,  and  brawny,  considerable 
weight  and  lancinating  pain  being  complained  of.  Such  abscesses  are  very 
slow  in  coming  to  the  surface  because  of  the  comparative  density  of  Buck's 


COMPLICATIONS   AND   EESULTS    OF    STEICTUEE.  257 

fascia,  which  binds  them  down.  If  the  pus  escapes  from  its  environment  of 
plastic  exudate,  it  is  most  apt  to  follow  the  course  taken  by  infiltrated  urine, 
there  being  less  resistance  to  burrowing  within  the  limits  of  Buck^s  fascia 
than  to  its  escape  externally. 

Treatment. — The  treatment  of  periurethral  and  perineal  abscess  con- 
sists of  free  incision  with  antiseptic  precautions.  It  is  bad  practice  to  wait 
for  fluctuation.  When  the  penile  urethra  is  affected  nothing  is  warrantable 
save  a  small  puncture  to  relieve  distension  and  prevent  rupture  into  the 
urethra.  Even  in  these  cases,  however,  if  puncture  demonstrates  the  pres- 
ence of  pus,  the  abscess-cavity  should  be  laid  freely  open.  In  perineal  ab- 
scess a  free  incision  should  be  made  into  the  induration  in  the  median  line; 
delay  may  lead  to  extravasation  of  urine.  The  after-treatment  should  con- 
sist of  the  ordinary  surgical  measures  for  the  treatment  of  abscess. 

Ueetheal  Fistulas. — Urethral  fistulas  result  from  extravasation  of 
urine  and  abscess.  They  are  usually  located  in  the  perineum  and  scrotum, 
but  have  been  noted  in  the  groin,  inner  aspect  of  the  thigh,  and  upon  the 
anterior  abdominal  wall  as  a  consequence  of  extensive  burrowing  of  pus. 
Their  point  of  departure  is  generally  in  the  bulbo-membranous  region;  ex- 
ceptionally they  are  met  with  in  the  scrotum  and  about  the  pendulous  ure- 
thra. When  perineal,  numerous  openings  may  be  found  about  the  peri- 
neum, nates,  scrotum,  and  perhaps  the  inner  aspect  of  the  thighs.  In  a 
case  of  Civiale's  over  fifty  external  openings  were  found  to  communicate 
with  the  perineal  urethra.  There  is  something  remarkable  in  the  manner 
in  which  pus  will  creep  about  and  form  secondary  fistulas  in  these  cases. 

The  number,  location,  size,  and  length  of  fistulas  are  cardinal  points  in 
deciding  their  importance.  Small  perineal  fistulas  with  a  single  or  perhaps 
two  openings  are  not  of  great  importance;  they  will  usually  close  spon- 
taneously after  all  urethral  obstructions  have  been  removed. 

The  size  of  fistulas  depends  entirely  upon  the  amount  of  loss  of  sub- 
stance. They  may  be  large  enough  to  admit  several  fingers.  They  are  gen- 
erally tortuous,  narrow,  and  extend  for  a  considerable  distance.  The  ex- 
ternal orifice  may  be  very  narrow,  and  may  heal  from  time  to  time  only  to 
reopen.  Under  such  circumstances  the  urine  remains  in  the  fistula,  decom- 
poses, and  again  produces  suppuration,  with  external  discharge.  In  some 
instances  burrowing  occurs,  with  resulting  tributary  fistulas  running  in 
various  directions.  In  cases  of  multiple  fistulas,  the  tissues  of  the  scrotum, 
penis,  and  perineum  become  extremely  hard  and  thickened,  feeling  almost 
like  cartilage.  Where  the  stricture  is  tight  and  the  fistula  large,  the  urine 
may  not  pass  through  the  normal  channel,  escaping  entirely  via  the  fistula. 
Earely,  indeed,  does  the  stricture  become  completely  agglutinated,  although 
such  an  accident  may  possibly  occur  in  cases  of  traumatic  stricture. 

Treatment.  —  The  treatment  of  fistulas  depends  upon  their  location, 
number,  and  the  amount  of  substance  lost.  The  first  indication  is  the  re- 
moval of  all  obstructions  to  the  outflow  of  urine.     A  contracted  meatus 


358 


STRICTUEE    OF   THE    UEETHRA. 


and  penile  strictures  require  division.  Care  should  be  taken  to  completely 
restore  the  caliber  of  the  urethra;  the  more  perfectly  this  is  done  the  less 
resistance  there  is  to  the  outflow  of  urine.  By  this  procedure  advantage  is 
taken  of  the  law  that  fluid  tends  to  flow  in  the  direction  of  least  resistance. 
Should  there  be  sufficient  obstruction  at  any  point  to  produce  distension 
of  the  urethra  behind  it^  the  backward  and  outward  pressure  will  neces- 
sarily force  a  portion  of  the  urine  into  the  internal  orifice  of  the  fistula  and 
thus  prevent  healing.  The  majority  of  simple  perineal  fistulas  close  spon- 
taneously after  urethrotomy  or  successful  dilation.  The  tissues  in  this 
situation  are  thick^  and  reparative  action  is  consequently  much  more  active 
than  in  the  penile  urethra.  Then,  too,  the  parts  are  not  disturbed  by  erec- 
tions, which,  by  preventing  rest,  necessarily  retard  granulation  and  healing. 
Should  simple  fistula  show  a  tendency  to  chronicity,  the  patient  should 


■  ■"'''■by^i 


Fig.  84. — Multiple  urinary  fistulas  from  deep  stricture.     (After  Bryant.) 


be  instructed  to  draw  his  urine  at  regular  intervals,  thus  obviating  its 
passage  via  the  fistula.  If  this  plan,  however,  produces  irritation  of  the 
urethra  and  bladder,  it  should  be  discontinued. 

Eepair  may  often  be  stimulated  by  cauterizing  the  fistula.  A  good 
plan  is  to  enlarge  its  external  orifice,  pare  its  edges,  and  then  cauterize  the 
track  with  a  fine  platinum  galvanocautery-wire  passed  into  the  fistula  cool, 
then  heated  to  a  white  heat  and  rapidly  withdrawn.  A  fine  probe,  coated 
with  a  bead  of  sulphate  of  copper  or  nitrate  of  silver,  may  be  used  for 
cauterization.  After  the  operation  a  soft,  moderate-sized  catheter  should 
be  left  in  the  bladder  to  prevent  escape  of  the  urine  through  the  fistula 
and  retained  for  several  days.  The  viscus  should  be  irrigated  with  a  warm, 
mild,  antiseptic  solution  at  least  once  daily.  Applications  of  tincture  of 
iodin  upon  a  cotton-wrapped  probe  sometimes  promote  healing. 


COMPLICATIONS    AND    EESULTS    OF    STKICTUEE. 


359 


If  the  stricture  be  hard,  resilient,  or  irritable  perineal  section  is  ad- 
visable. All  branching  fistulas  that  can  be  reached  should  be  laid  open 
and  left  to  granulate.  After  perineal  section  in  stricture  complicated  by 
fistulas  perineal  drainage  should  be  adopted.  This  not  only  drains  the 
bladder,  but  prevents  the  urine — which  is  invariably  irritating — from  com- 
ing in  contact  with  the  fistulas.  Fistulas  involving  the  scrotum  often  re- 
quire free  incision  after  the  removal  of  urethral  obstructions.    Such  fistulas 


Symanowski's  urethroplasty  for  penile  urinary  fistula. 


are  often  connected  with  unhealthy,  sloughy  abscess-cavities.  These  should 
be  laid  freely  open. 

Siphon-drainage  has  been  recommended  for  simple  perineal  fistulas. 
A  soft  catheter  of  moderate  size  is  tied  in  the  bladder  and  attached  to  a 
rubber  tube  that  passes  into  a  receptacle  containing  carbolized  water.  A 
number  of  cases  have  been  cured  in  this  manner. 

Urinary  fistulas  occasionally  open  into  the  rectum,  in  which  event  we 
have,  superadded  to  the  obstacle  to  healing  afforded  by  the  contact  of  urine. 


g60 


STEICTUEE    OF   THE   URETHRA. 


the  escape  of  fecal  matter  and  gas.  These  materials  are  likely  to  pass,  not 
only  into  the  fistula,  but  through  it  into  the  urethra.  Fistulas  of  this  sort 
are  not  apt  to  heal  even  after  the  urethra  has  been  restored  to  its  normal  cal- 
iber. The  ordinary  operation  for  rectal  fistula  should  be  performed  in  such 
cases,  the  rectum  and,  so  far  as  possible,  the  track  of  the  urinary  fistula 
being  laid  into  one  cavity  to  granulate  from  the  bottom.  The  rectal  ex- 
tremity of  the  fistula  having  healed,  there  may  still  be  an  opening  in  the 
perineum,  the  urine  alone  being  sufficient  to  keep  the  urethral  end  from 
closing.  The  perineal  fistula  may  now  be  treated  as  under  ordinary  cir- 
cumstances. 

Thompson  records  an  instance  of  successful  treatment  of  recto-urethral 
fistula  by  position,  the  patient  being  instructed  to  pass  urine  only  in  the 
prone  position. 

Large  fistulas  due  to  destruction  of  tissue  require,  as  a  rule,  special 


Fig.  89. — Szymanowski's  operation  for  large  penile  fistula. 


operative  measures.  The  same  is  true  of  fistulas  that  fail  to  heal  under  the 
measures  already  outlined.  Penile  fistulas,  with  or  without  loss  of  sub- 
stance, are  apt  to  be  intractable.  This  is  due  to  extreme  tenuity  of  the 
tissues,  which  is  unfavorable  to  plastic  exudate  and  repair,  and  to  the  vari- 
able position  of  the  organ  incidental  to  erection,  which  prevents  the  neces- 
sary rest.  Even  with  considerable  loss  of  substance,  perineal  fistulas  often 
close  spontaneously,  granulation  and  repair  being  very  active  and  the  parts 
infrequently  disturbed.  Loss  of  substance  may  occur  in  fistulas  due  to 
gangrene  and  sloughing,  extensive  abscess,  phagedena,  or  the  prolonged 
contact  of  urethral  instruments  or  foreign  bodies.  They  are  necessarily 
most  often  noted  in  severe  strictures. 

Urethroplasty  is  usually  necessary  in  large  fistulas  of  the  penile  ure- 
thra. Astley  Cooper,  however,  reported  a  ease  in  which  applications  of 
nitric  acid  succeeded  in  closing  a  fistula  as  large  as  a  good-sized  pea  after 
two  successive  plastic  operations  had  failed.    Dieffenbaeh  has  suggested  the 


UEETHEOPLASTY. 


261 


application  of  a  strong  tincture  of  cantharides,  which  destroys  the  epithe- 
lium and  stimulates  granulation. 

Perineal  fistulas  may  often  be  closed  by  a  comparatively  simple  opera- 
tion. The  edges  should  be  liberally  pared  and  brought  together  with  a 
quilted  or  shotted  suture.  The  author  has  succeeded  in  curing  several  by 
repeated  suturing  after  preliminary  cauterization.  Another  simple  proced- 
ure that  has  served  well  in  two  cases  following  perineal  section  is  as  follows: 
The  edges  and  track  of  the  fistula  are  first  cauterized  with  nitric  acid. 
Three  days  later  the  track  of  the  fistula  is  dissected  up  almost  to  the 
urethra  and  the  portion  of  tissue  containing  the  fistula  twisted  upon  itself 
several  times,  after  which  it  is  anchored  with  a  suture  and  the  wound 
stitched  closely  around  it. 

Scrotal  fistulas  require  free  paring  of  their  edges.     The  tissues  about 


Fig.  90. — Nelaton's  operation  for  penile  fistula. 


the  fistula  should  be  extensively  dissected  up  to  secure  thick,  good-sized 
flaps  of  skin  and  areolar  tissue.  These  should  be  stitched  together  with 
silver-wire,  silk-worm-gut,  or  the  quilted  or  shotted  suture.  Several  opera- 
tions may  be  necessary,  each  operation  making  the  fistula  smaller.  The 
urine  must  be  drawn  by  the  catheter.  If  the  urethra  be  tolerant  of  the 
instrument,  a  soft  catheter  of  medium  size  may  be  retained  for  several  days. 
Irrigation  of  the  bladder  is  necessary  to  keep  it  aseptic  so  far  as  possible; 
so  that,  if  urine  does  get  in  the  wound  it  is  not  so  likely  to  prevent  healing. 
As  a  substitute  for  plastic  methods  Dieffenbach  proposed  a  very  simple 
operation.  A  concentrated  tincture  of  cantharides  is  applied  to  the  edges 
and  track  of  the  fistula.  As  soon  as  the  epithelium  has  become  detached 
and  the  surfaces  are  sufficiently  raw,  a  good-sized  soft  bougie  is  introduced 
into  the  canal;  a  needle  armed  with  a  strong,  well-waxed  silk  thread  is  now 


262 


STEICTUEE    OF   THE    URETHRA. 


introduced  about  a  quarter  of  an  inch,  from  the  fistulous  opening.  This  is 
passed  into  the  corpus  spongiosum  for  a  short  distance,  then  made  to 
emerge.  It  is  reintroduced  at  the  point  of  emergence,  passed  along,  and 
brought  out  again  in  the  same  manner  and  at  the  same  distance  from  the 
edge  of  the  fistula.    This  is  repeated  until  the  ligature  completely  encircles 


Fig.  91. — Nelaton's  operation  for  penile  fistula. 

the  fistula  and  terminates  at  the  original  point  of  introduction.  The  thread 
bears  the  same  relation  to  the  fistula  that  a  draw-string  does  to  the  mouth 
of  a  bag.  The  two  ends  of  the  ligature  being  drawn  together,  the  freshened 
surfaces  of  the  fistula  are  closely  approximated.  A  knot  is  now  tied  and 
allowed  to  sink  into  the  point  of  puncture.     The  urine  is  to  be  drawn  at 


Fig.  92. — Clark's  operation  for  penile  fistula:    first  step. 

regular  intervals  by  the  catheter.  The  ligature  is  allowed  to  remain  for 
three  or  four  days,  then  cut  and  withdrawn.  Several  operations  may  be 
necessary  before  the  fistula  is  obliterated.  The  operation  is  only  applicable 
to  small  fistulas. 

In  the  penile  urethra  it  is  quite  difficult  to  perform  a  successful  ure- 


UEETHEOPLASTT. 


263 


throplasty  on  account  of  the  thinness  and  looseness  of  the  integument  and 
sparsity  of  cellular  tissue.  So  scanty  are  the  tissues  that  the  surgeon  natu- 
rally hesitates  to  pare  the  surfaces  of  the  fistula  sufficiently  to  insure  the 
desired  result.  Obviously,  flaps  with  such  thick  edges  as  can  be  secured  in 
the  perineum  heal  more  readily  than  the  thin  ones  that  it  is  practicable  to 
secure  in  the  penile  urethra.  The  disquiet  and  tension  produced  by  erec- 
tions constitute  another  obstacle  to  success. 

Several  special  operations  of  urethroplasty  have  been  devised.  One  of 
the  best  is  that  of  Szymanowski  (Figs.  85  to  89).  This  operation  is  per- 
formed in  the  following  manner:  When  the  fistula  lies  in  the  long  axis  of 
the  penis,  a  straight  incision  is  first  made,  beginning  immediately  in  front 
of  the  fistula  and  terminating  just  behind  it.  The  integument  upon  one  side 
is  then  dissected  up  until  freely  movable.  A  half-oval  flap  of  skin  on  the  op- 
posite side  is  then  outlined  and  dissected  up,  excepting  at  the  edge  of  the 
fistula,  its  epidermis  being  first  removed.    The  dissected  flap  is  inverted  and 


Fig.  93. — Clark's  operation  for  penile  fistula:    second  step. 

pushed  under  the  skin  that  has  been  freed  upon  the  opposite  side,  as  into 
a  pocket,  where  it  is  retained  in  position  by  sutures  passed  into  and  through 
the  bottom  of  the  pocket.  The  movable  skin  is  then  slid  over  it  and  also 
stitched.    A  soft  catheter  is  passed  into  the  bladder  and  retained. 

ISTelaton's  operation  has  been  somewhat  popular.  It  is  performed  in 
the  following  manner:  The  edges  of  the  fistula  are  first  freely  pared;  the 
surrounding  skin  for  an  area  of  about  an  inch  in  breadth  and  extending  a 
little  beyond  the  fistula  anteriorly  and  posteriorly  should  then  be  dissected 
subcutaneously  by  a  narrow-bladed  knife  introduced  posterior  to  the  fistula. 
The  raw  edges  of  the  latter  are  then  brought  together  by  fine  sutures. 

Another  method  was  proposed  by  the  same  surgeon.  The  edges  of  the 
fistula  are  first  pared  and  the  skin  separated  for  about  half  an  inch  upon 
each  side  of  the  opening.  Lateral  incisions  are  then  to  be  made  at  a  dis- 
tance of  about  half  an  inch  from  the  pared  edges  to  relieve  tension,  A  slip 
of  thin  India-rubber  tissue  is  then  passed  beneath  the  skin-flaps  to  prevent 


264  STKICTUEE    OF   THE    UEETHRA. 

contact  of  iirine  with  the  raw  edges  and  consequent  disturbance  of  adhesion. 
Should  the  fistulous  opening  close,  the  lateral  incisions  promptly  heal.  In 
both  of  Nelaton^s  operations  the  extensive  separation  of  skin  causes  abun- 
dant granulations  to  spring  up,  often  closing  the  fistula. 

In  extensive  penile  fistulas  perineal  drainage  should  be  established  after 
a  plastic  operation  has  been  performed. 

Eicord  recommended,  for  cases  in  which  perineal  or  scrotal  fistulas  co- 
exist with  fistulas  in  the  pendulous  urethra,  that  a  catheter  be  passed 
through  the  lower  fistula  to  drain  the  bladder  during  treatment  of  the  penile 
lesion.  He  also  suggested  puncturing  the  bladder.  Erichsen  recommends 
that  this  be  done  through  the  rectum;  but  perineal  drainage  is  far  better. 
The  perineal  opening  made  by  this  latter  operation  will  almost  invariably 
close  spontaneously  when  it  has  subserved  its  function. 

The  following  operation  for  extensive  penile  fistula  was  recommended 
by  Le  Gros  Clark  (Figs.  92  and  93):  The  edges  of  the  fistula  having  been 
thoroughly  pared,  a  transverse  cut  about  an  inch  in  length  is  made  through 
the  penile  integuments  a  little  distance  in  front  of  the  fistula  (a).  Two 
transverse  incisions  are  then  made  at  the  peno-scrotal  angle,  each  being 
about  an  inch  and  a  half  in  length.  These  transverse  incisions  are  con- 
nected at  each  end  by  a  short  longitudinal  incision  (&).  The  flaps  of  skin 
thus  outlined  are  dissected  up  and  brought  together  by  means  of  clamps  or 
the  quilled  suture.  By  this  procedure  two  broad  raw  surfaces  (at  c)  are 
brought  together  instead  of  a  narrow  raw  edge  of  skin,  thus  increasing  the 
chances  of  perfect  union.  In  extensive  fistulas  it  may  be  well  to  divert  the 
urine  from  the  urethra  altogether,  by  combining  suprapubic  drainage  with 
urethroplasty. 


PART  IV. 

CHANCEOID  AND  BUBO  AND  THEIR  COMPLICATIONS. 


CHAPTER  XII. 
Chanceoid. 

Definition.  —  The  best  definition  of  chancroid  is  probably  that  of 
Fonrnier,  who  says:  "Chancroid  is  a  specific  malady  consisting  in  a  peculiar 
ulcer,  secreting  a  virulent,  autoinoculable  pus.  It  is  exclusively  local,  and 
never  gives  rise  to  constitutional  symptoms.^^^ 

HiSTOEY. — Chancroid,  or  the  local  contagious  venereal  ulcer,  was  for- 
merly supposed  to  be  identic  with  syphilis,  and  the  term  chancre  was  ap- 
plied indiscriminately  to  all  venereal  lesions,  ulcerative  or  indurated,  ap- 
pearing upon  the  male  or  female  genitals.  During  what  has  been  appro- 
priately termed  the  "period  of  venereal  confusion"  the  greatest  ignorance 
prevailed  as  to  the  origin,  natural  history,  and  management  of  venereal  dis- 
eases. Only  within  comparatively  recent  years  has  there  been  anything  ap- 
proaching unanimity  of  opinion  among  leading  surgical  scientists  concern- 
ing them.  Authorities  of  a  century  ago  evidently  had  no  conception  of  the 
physiologic  and  pathologic  facts  that  should  have  guided  them  in  their 
studies,  and  as  a  result  eminent  men  reached  widely  different  conclusions, 
from  practically  identic  observations.  According  to  John  Hunter,  there 
was  but  one  venereal  disease,  which  decidedly  complex  affection  included 
the  affections  that  we  now  term  gonorrhea,  chancroid,  and  syphilis.  Fifty 
years  after  the  appearance  of  Hunter's  famous  treatise  in  which  he  claimed 
the  unity  of  the  venereal  diseases,  Eicord  demonstrated  the  existence  of  two 
distinct  diseases,  gonorrhea  and  syphilis,  but  failed  to  appreciate  any  differ- 
ence between  the  venereal  sore  that  we  now  know  to  be  local  and  non-con- 
stitutional and  that  which  is  always  a  manifestation  of  a  general  infectious 
disease.  Some  years  later  Bassereau  demonstrated  the  duality  of  syphilis 
and  chancroid. 

The  then  novel  theory  of  Bassereau  was  not  immediately  accepted,  but 
eventually  the  majority  of  syphilographers  came  to  consider  it  as  positively 
demonstrated.  There  are  still,  however,  a  few  men  of  surgical  prominence 
who  are  unwilling  to  east  off  the  ancient  belief  that  all  venereal  sores  are 


^  This,  of  course,  covers  only  uncomplicated  chancroid.     Phagedena  and  inflam- 
mation may  cause  marked  constitutional  disturbance. 

(265) 


266 


CHAXCKOID. 


syphilitic.  Some  English  authors  still  speak  of  chancroid  as  "local  syph- 
ilis":  a  term  first  applied  by  Lancereaux.^ 

The  Geem  oe  Chaxceoid. — That  chancroid  is  a  germ  disease  is  hardly 
open  to  question,  yet  experimental  researches  so  far  undertaken  to  demon- 
s.rate  the  Sj^;eciP.c  microbe  haye  been  exceedingly  unsatisfactory  and  incon- 
clusive. Ducrey  and,  following  him,  Unna  have  been  more  positiye  in  their 
conclusions  than  others,  and  their  researches  have  been  repeated,  and  their 
claims  substantiated  by  Krefting  and  Wielander.  Investigators  of  equal 
ability,  among  whom  are  Strauss  and  Jullien,  have,  on  the  other  hand, 
denied  the  accuracy  of  the  observations  of  Ducrey  and  Unna.  Inasmuch  as 
cultures  outside  of  the  body  have  not  thus  far  been  made,  the  case  of  the 
specific  chancroidic  microbe  has  by  no  means  been  proved. 

The  Ducrey-Unna  bacillus  is  described  as  a  short,  thick  bacillus,  with 
rounded  ends  and  a  central  constriction,  somewhat  resembling  a  dumb-bell. 


Fig.  93o. — Section  of  chancroid  showing  Ducrey-Unna  streptobacillus  in  the 
tissues.  The  bacillus  is  comi^osed  of  small  rods  arranged  in  chains. 
(After  Taylor.) 

The  germ  is  located  both  in  the  cell-protoplasm  and  between  the  cells.  In 
the  discharge  from  the  original  chancroid,  the  specific  microbe  is  relatively 
scarce,  but  in  successive  pustules  from  autoinoculation  the  other  microbes 
progressively  disappear,  while  the  chancroidic  germ  grows  more  abundant. 
It  is  claimed  that  in  the  third  autoinoculation  pustule  a  pure  culture  of  the 
specific  microbe  "is  found. 

Prior  to  the  claim  that  chancroid  is  a  germ  disease  the  contagious  prin- 


^  In  his  Lettsomian  lectures,  some  years  since,  Mr.  Jonathan  Hutchinson  ex- 
pressed the  opinion  that  chancroid  usually  occurs  in  persons  whose  systems  have  been 
impressed  by  syphilis  at  a  period  more  or  less  remote.  In  other  words,  he  believes  that 
chancroid  is  a  mild  manifestation  of  syphilis  in  a  person  who  has  already  been 
syphilized.     This  theory  is  as  untenable  as  it  is  striking. 


OEIGIN    OF    CHAXCEOID.  367 

ciple  was  believed  to  reside  in  the  pus-corpuscle.  It  is  asserted  by  EoUet  that 
filtration  removes  all  noxious  properties  from  the  fluid  secretion.  This,  if 
verified,  Avould  practically  eliminate  toxins  from  the  destructive  action  of 
chancroid.  Those  who  have  advocated  the  germ-origin  of  chancroid  claim 
that  its  germ,  like  that  of  gonorrhea,  acts  by  incorporating  itself  with  the 
pus-corpuscles.    Demonstration  of  this  would  support  EoUet^s  assertion. 

Oeigin  of  Chancroid. — Clinical  observation  has  apparently  demon- 
strated that,  germ  or  no  germ,  the  materies  viorli  of  chancroid  originates 
de  novo  in  certain  conditions  of  the  genitals.  Its  principal  source  is  the 
female  genitalia;  rarely,  yet  none  the  less  certainly,  it  develops  spontane- 
ously in  the  male.  The  conditions  favoring  its  development  are  those  that 
favor  germ-growth  in  general.  These  conditions  probably  not  only  originate 
chancroid,  but  gonorrhea  and  its  congeners  as  well. 

As  remarked  in  the  discussion  of  gonorrhea,  it  is  no  more  conceivable 
that  the  germs  of  infectious  diseases  were  specifically  created  than  that  the 
animals  upon  which  they  feed  were  originally  created  of  a  fixed  and  unvary- 
ing type.  Man  is  subservient  to  the  same  evolutionary  laws  of  progression 
and  diff'erentiation  as  all  other  forms  of  life.  G-ranting  this  in  the  case  of 
man, — the  host, — it  must  also  be  granted  in  the  case  of  the  disease-germ — 
the  parasite  that  feeds  upon  him. 

Living  germs  of  innocuous  type  are  found  upon  practically  all  the 
mucous  membranes  of  the  human  body.  These  germs  retain  their  innocu- 
ous character  just  so  long  as  their  environment  and  the  pabulum  on  which 
they  feed  remain  unchanged.  With  a  sudden  radical  change  of  these  con- 
ditions comes  extinction  of  the  germ.  With  a  gradual  change  extinction 
would  also  come,  were  it  not  that  the  germ  adapts  itself  to  its  changing 
environment  and  food-supply.  With  this  adaptation  comes  a  change  in  the 
properties  of  the  germ,  viz.:  (1)  in  its  physical  properties  in  a  minor  degree, 
if  at  all;  (3)  in  its  vital  properties  in  a  degree  depending  on  the  duration, 
accentuation,  and  character  of  the  environmental  and  food-changes  to  whicli 
it  is  subjected. 

The  truth  of  the  foregoing  proposition  cannot  be  denied  without  de- 
stroying the  foundation  and  overthrowing  the  entire  superstructure  of  evo- 
lution. In  maintaining  the  origin  of  gonorrhea  and  chancroid  de  novo  it  is 
in  nowise  claimed  that  spontaneous  generation  of  disease-germs  occurs  in 
the  genitalia — ^though  this  is  by  no  means  impossible,  Pasteur's  experiments 
to  the  contrary  notwithstanding.  The  author's  view  is,  briefly,  that — through 
evolutionary  changes — (1)  primarily  innocuous  germs — whether  entering 
from  the  outside  or  having  their  natural  habitat  in  the  genitalia,  especially 
in  the  female — may  become  pathogenic;  (3)  that  germs  of  mild  pathogenic 
properties — e.g.,  pus-microbes — may  acquire  a  new,  or,  at  least,  a  severer, 
type  of  pathogenic  power;  (3)  that  the  character  and  severity  of  the  re- 
sulting pathogenesis  (i.e.,  the  degree  and  quality  of  virulency)  varies  with 
(a)  the  duration  of  the  process,  (b)  the  character  of  the  local  conditions,  (c) 


268  CHANCEOID. 

the  condition  of  the  secretions,  and  (d)  the  susceptibility  of  the  individual — 
of  which  more  anon. 

The  origin  of  chancroid  and  gonorrhea  must  necessarily  be  the  same 
if  the  evolutionary  theory  of  their  origin  be  correct.  The  vagina  of  the 
female  is  an  excellent  nidus  or  hot-bed  for  the  cultivation  of  germs.  Con- 
sidering the  large  number  of  women  affected  by  utero-vaginal  disease,  it  is 
surprising  that  the  venereal  affections  are  so  few  in  number  and  so  uniform 
in  manifestations. 

There  exist  in  the  vagina,  even  in  healthy  women,  the  circumstances 
of  heat,  moisture,  protection  from  air  and  light,  and,  very  often,  local  irri- 
tation incident  to  excessive  cohabitation.  Superadd  to  these  normal  or 
quasinormal  conditions  a  suitable  pabulum  for  the  development  of  germs  in 
the  form  of  decomposing  uterine  or  seminal  discharges,  and  conditions 
detrimental,  not  only  to  the  woman  herself,  but  also  to  the  generative  organs 
of  anyone  with  whom  she  may  chance  to  have  sexual  congress,  are  likely 
to  develop.  Few  women  are  free  from  disease;  indeed,  the  woman  who  is 
perfectly  sound  is  a  ra7-a  avis,  and  in  the  uterine  discharges  bacteria  may 
develop  and  wax  fat.  Many  women — through  ignorance  in  some  eases, 
through  natural  physical  indifference  in  others — are  exceedingly  unclean, 
and  allow  both  natural  and  unnatural  secretions  to  accumulate  until  the 
condition  of  their  sexual  organs  is,  indeed,  filthy.  This  is  especially  the 
case  in  the  low-class  prostitute,  and  unfortunately  is  often  the  case  among 
women  who  are  respectable  or  quasirespectable.  The  high-toned  prostitute 
is  not  so  open  to  impeachment  upon  this  score. 

As  the  circumstances  of  uncleanliness,  imhealthy  secretions,  local  irri- 
tation, heat,  moisture,  and  absence  of  free  air  and  light  favor  the  develop- 
ment of  germs,  and  particularly  those  of  decomposition,  it  may  be  readily 
understood  that  sooner  or  later  such  bacterial  development  frequently  takes 
place  in  the  vagina.  The  innocuous  germs  of  the  atmosphere  enter,  and 
begin  their  work  of  procreation  or  multiplication  in  an  environment  scanty 
in  its  supply  of  oxygen^;  decomposition  occurs,  and,  pari  passu  with  it,  (1) 
new  germs  appear  upon  the  scene  that  differ  from  the  parent-stock;  (2) 
germs  normally  found  in  the  vagina  undergo  transformation,  and  so  the 
process  goes  on  until  pathogenic  microbes  and  irritating  toxins  are  devel- 
oped. 

If,  during  this  time,  the  microbe-bearing  discharge  from  a  diseased 
urethra  be  deposited  in  the  vaginal  culture-bed,  so  much  the  better  for  the 
development  of  "specific"  pathogenic  germs.  Selmi  and  Gautier  showed 
long  ago  that  poisonous  alkaloids  develop  from  germ-evolution.     To  these 


^  The  experiments  of  Pasteur  on  the  germ  of  chicken-cholera  are  of  interest  in 
this  connection.  In  the  hope  of  diminishing  the  infective  power  of  £his  organism,  he 
grew  it  in  oxygen  for  a  long  time,  and  found  that  it  produced  a  modified  disease  that 
in  most  cases  protected  the  animal  from  the  effect  of  the  organisms  in  their  most 
virulent  state.    British  Medical  Journal,  December  31,  1881,  p.  1062. 


OEIGIN    OF    CHANCROID.  369 

poisonous  substances  or  toxins  much,  of  the  pathology  of  gonorrhea  and 
chancroid  may  be  due.  The  decomposition  of  semen — a  highly-  and  com- 
plexly- organized  compound— is  especially  likely  to  produce  such  a  toxin. 
If  this  be  correct,  it  is  probable  that  it  is  to  the  products  of  the  bacteria, 
rather  than  to  the  bacteria  themselves,  that  we  should  attribute  some  of  th.e 
results  of  gonorrheal  and  especially  chancroidic  secretions.  It  is  therefore 
assumed  that,  while  bacteria  are  undoubtedly  the  foundation  of  gonorrhea 
and  chancroid,  they  are  probably  not  the  cause  of  all  their  phenomena.  It 
is  possible  for  the  toxins  in  themselves  to  produce  mucous  inflammation  or 
tissue-destruction.  This  would  explain  why  scientific  observers  have  found 
bacteria  or  cocci  in  some  cases,  while  they  have  been  unable  to  do  so  in  others 
of  apparently  similar  type.  The  varying  degree  of  acridity  and  quantity  of 
toxins  produced  by  different  germs,  and  the  varying  susceptibility  of  mu- 
cous membranes  would  explain  the  variations  in  type  and  severity  of  cases 
of  urethritis  and  chancroid. 

The  conditions  modifying  the  results  of  the  evolution  of  germs  and 
germ-toxins  in  the  human  vagina  are  as  follow: — 

1.  It  is  obvious  that  much  depends  upon  (a)  the  age  of  the  decom- 
position; (&)  the  nature  and  degree  of  inflammation  present;  (c)  the  fre- 
quency of  coitus;  (d)  the  constitution  and  habits  of  the  woman;  (e)  the 
character  of  any  germ-bearing  semen  or  urethral  discharges  that  may  be 
deposited  in  the  vagina;  (/)  the  character  of  germs  entering  through  acci- 
dental means  other  than  by  sexual  congress;  (g)  the  character  of  the  normal 
germ-inhabitants  of  the  sexual  tract,  especially  in  the  female. 

2.  The  amount  and  degree  of  viru.lency  of  the  cultivated  germs  or 
germ-toxins  deposited  upon  an  absorbent  surface  in  another  individual. 

3.  The  cleanliness,  local  and  constitutional  condition,  habits,  and  sex- 
ual hygiene  of  the  recipient  of  the  cultivated  virus. 

4.  Individual  predisposition. 

With  reference  to  the  latter  point,  Jordan  Lloyd  says: — 

There  can  be  no  doubt  that  some  individuals  contract — and  even  develop — 
venereal  disease  much  more  readily  than  do  others.  There  can  be  no  doubt  that  all 
physicians,  from  the  nature  of  their  calling,  must,  during  the  course  of  each  year,  be 
exposed  to  infection  of  one  kind  or  another  many  hundreds  of  times.  Physicians, 
however,  do  not  take  any  particular  precautions  in  the  way  of  protecting  themselves 
from  these  influences.  Immunity  does  not,  in  every  case,  depend  upon  their  having 
already  suffered  from  attacks  of  the  various  infectious  diseases.  How  is  it,  then, 
that  they  so  rarely  become  affected?  It  is  because  they  have  not  the  predisposition, 
whatever  that  word  may  mean;  because  their  bodies  do  not  present  a  suitable  nidus 
for  the  growth  and  development  of  the  germs  of  disease.  Again,  in  a  class  of  cases 
more  closely  allied,  clinically  and  pathologically,  to  those  under  discussion,  how 
often  do  we  see  among  hospital  officers  men  who  are  frequently  developing  crops  of 
hospital  furuncles  on  their  hands  and  arms,  others  with  constantly  recurring  sore 
throat;  others  with  inflamed  wounds  and  lymphatics  from  post-mortem  abrasions; 
while  at  the  same  time  and  under  precisely  the  same  conditions,  there  will  be 
men  who,  year  after  year,  remain  free  from  all  such  troubles.     Susceptibility  of  one 


270  CHAXCEOID. 

class  of  individuals  to  certain  poisonous  influences  or  insusceptibility  of  the  other 
must  be  the  explanation.  There  is  nothing  more  strange  in  it  than  in  that  of  many 
of  the  well-known  "idiosyncrasies";  for  example,  the  poisonous  effects  of  eggs  and 
tobacco  on  certain  persons. 

There  is  a  certain  class  of  persons  who  are  familiar  to  eveiy  observant  physician 
as  "suppuraters."  This  is  the  class  of  people  in  whom,  as  we  well  know,  wounds  are 
more  likely  to  heal  by  granulation  than  by  first  intention.  These  people,  apparently 
of  robust  health  and  iron  constitutions,  frequently  have  boils.  When  their  lymphatic 
glands  inflame,  as  they  often  do,  the  process  more  often  terminates  in  suppuration 
than  resolution;  trivial  wounds  in  such  people  do  not  heal  at  once;  they  heal  by 
granulation.  I  believe  these  suppuraters  contract  venereal  diseases  where  ordinary 
mortals  escape  them.^ 

The  final  result  of  microbial  cultivation  in  the  female  sexual  tract  de- 
pends mainly  upon  the  character  and  properties  of  the  germs  pre-existing 
or  primarily  inoculated  in  the  vaginal  culture-bed.  There  are  numerous 
organisms  that  may  find  their  way  into  the  vagina  or  which  exist  in  it  nor- 
mally.   The  most  important  of  these  are: — 

1.  Simple  cocci  resembling  the  urethrococcus  and  gonococcus. 

2.  Urethrococci,  strongly  resembling  the  gonococcus. 

3.  Pyogenic  microbes — both  staphylococci  and  streptococci. 

4.  The  hacterium  coli  commune. 

5.  Gonococci. 

6.  Micrococcus  citreus  conglomeratus. 

7.  Diplococcus  albicans  tardissimus. 

8.  Diplococcus  aTbicans  amplus. 

9.  Micrococcus  suhfaviis. 

10.  Microbes  of  decomposition,  such  as  (a)  bacillus  suhtilis;  (b)  bac- 
terium urece;    (c)  micrococcus  urece;    (d)  spirillum  concentricum. 

Considering  the  possibilities  of  microbial  cultivation  and  variation 
demonstrated  by  every-day  laboratory  experiment,  the  excellence  of  the 
vagina  as  a  culture-field — a  field  far  superior  to  any  laboratory  imitation, 
the  variety  of  possible  culture-media  offered  by  the  sexual  tract,  and,  finally, 
the  large  number  and  variety  of  microbes  having  access  to  the  female  sexual 
tract,  the  spontaneous  variation  in  type  and  pathogenic  properties  of  the 
germs  found  in  utero-vaginal  secretions  and  discharges  are  in  nowise  re- 
markable. Nor  is  it  at  all  illogical  to  infer  that  so-called  specific  microbes 
have  their  origin  in  a  variation  of  germs  that  are  primarily  non-pathogenic. 
The  author  ventures  to  assert  that  the  future  history  of  venereal  pathology 
will  show  the  truth  of  the  evolutionary  theory  of  the  origin  of  the  microbes 
of  the  local  venereal  diseases  for  which  he  has  so  long  contended. 

Since  the  publication  of  the  author's  first  papers  on  the  subject^  labora- 


I 


^  Birmingham  Medical  Eeview,  October,  1886. 

-  "The  Evolution  of  the  Local  Venereal  Diseases."  New  York  Medical  Record, 
vol.  xxxvii,  No.  2;  Medical  Age,  February  10,  1890;  and  St.  Louis  Medical  Review, 
February  22,  1890. 


VAEIATION    OF    laSTFECTION.  271 

tory  research  lias  shown  actual  transformations  of  pathogenic  microbes 
along  evolutionary  lines.  Variations  in  virnlency  were  shown  long  ago  by 
Pastenr.  If  the  bacteriologic  laboratory  can  show  such  results,  Xature's 
laboratory  should  be  expected  to  produce  far  more  wonderful  transforma- 
tions. 

Under  the  head  of  local  conditions,  vaginitis,  inflammation  of  Bartho- 
lin's glands,  endocervicitis,  vesical  and  prostatic  disease,  phimosis,  ure- 
thritis, paraphimosis,  balanitis,  posthitis,  and  herpes  not  only  modify  the 
course  of  chancroid,  but  indubitably  act  as  predisposing  causes. 

Vaeiation  of  Infection".  —  As  a  consequence  of  the  wide-spread 
variation  that  exists  in  the  foregoing  conditions,  there  may  result  from  dif- 
ferent inoculations  of  products  of  germ-evolution  different  degrees  of  in- 
fection. Thus,  the  disease  acquired  by  exposure  to  such  pathogenic  material 
may  be: — 

1.  Simple  balanitis,  balanoposthitis,  or  venereal  vegetations. 

2.  Simple  urethritis. 

3.  Virulent  urethritis  (gonococcic  urethritis). 

4.  Herpes  of  the  genitalia. 

5.  Simple  venereal  ulcer,  indistinguishable  from  advanced  herpes  or 
chancroid  in  process  of  healing. 

6.  Typic  chancroid. 

It  would  be  difficult  to  show  precisely  what  variation  in  germs  de- 
termines one  or  the  other  type  of  infection.  It  would  be  fair  to  assume 
that  the  primal  germ  is  different  in  gonorrhea  and  chancroid.  Thus,  the 
point  of  departure  in  the  former  may  be  simple  cocci  of  the  urethra  and 
vagina,  while,  in  the  case  of  the  latter,  some  one  or  other  of  the  pyogenic 
microbes,  or  perhaps  bacteria  of  decomposition,  may  constitute  the  parent- 
stock  in  the  pathogenic  germ-evolution.  The  evolution  of  both  germs  of 
decomposition  and  pyogenic  microbes  probably  gives  rise  to  an  intermediate 
series  of  germs,  of  varying  pathogenic  power,  that  may  excite  such  different 
degrees  of  mucous  inflammation  as  simple  urethritis,  balanitis,  simple  ulcer, 
etc.,  the  severity  of  the  inflammation  depending  upon  the  degree  of  germ- 
cultivation  and  the  primary  character  of  the  germ. 

Theoretic  considerations  aside,  there  are  numerous  clinical  facts  that 
not  only  indicate  the  origin  of  both  gonorrhea  and  chancroid  de  novo,  but 
seem  to  establish  the  correlation  of  the  two  diseases,  both  with  each  other 
and  with  simple  affections  of  various  kinds  and  degrees  of  severity.  Some 
of  these  clinical  facts  are  as  follow: — 

1.  The  discharge  from  urethritis  when  confined  by  a  tight  prepuce  is 
liable  to  cause  severe  inflammation  and  phimosis  (i.e.,  balanoposthitis).  If 
not  soon  relieved,  excoriations  and  even  chancroid-like  ulcerations  are  liable 
to  result. 

2.  The  discharge  from  these  lesions  as  well  as  that  from  gonococcic  or 


272  CHANCKOID. 

other  severe  types  of  urethritis  will  oftentimes  produce  a  pustule  by  lietero- 
inoculation  or  autoinoculation.  It  generally  produces  inflammation  at 
least,  and  in  cachectic  patients  ulceration,  identic  with  the  milder  types  of 
chancroid. 

3.  Long-continued  contact  of  both  gonorrheal  and  chancroidic  secre- 
tions with  mucous  membranes  often  causes  a  crop  of  venereal  vegetations. 
These  often  result  from  simple  irritating  secretions;  e.g.,  in  pregnant  women. 

4.  Urethral  chancroid  is  always  attended  by  urethritis  of  greater  or  less 
severity. 

5.  Gonorrhea  and  chancroid  are  often  associated,  appearing  either 
simultaneously,  or  at  such  interval  as  would  suggest  that  one  may  be  due 
to  the  secretion  of  the  other.  Both  being  mixed  infections  as  they  appear 
clinically,  this  correlation  is  not  surprising. 

6.  Both  diseases  are  most  often  contracted  from  the  same  low  class  of 
females;  more  rarely  from  the  higher  class. 

7.  Examination  of  women  from  whom  both  diseases  have  been  con- 
tracted by  different  men  often  shows  them  to  be  unclean,  but  free  from 
ordinary  clinical  evidences  of  either  disease. 

8.  Any  urethral  or  genital  lesion  may  be  followed  by  suppurating  bubo. 
The  author  has  successfully  autoinoculated  pus  from  a  bubo  sequent  to 
balanitis.  Mixed  infection  again  comes  in  play  in  explanation  of  the  simi- 
larity of  the  two  diseases  as  regards  glandular  infection. 

9.  It  is  usually  difficult  to  say  where  simple  genital  ulcer  terminates 
and  chancroid  begins.  The  test  of  autoinoculation  is  hardly  fair,  as  it  pos- 
sibly determines,  after  all,  merely  the  degree  of  virulency  of  the  infection. 

10.  The  natural  tendency  of  chancroid  is  to  lose  its  specificity,  after  a 
time,  and  assume  the  characteristics  of  simple  ulcer.  This  is  suggestive  of 
reversion  of  type,  to  say  the  least. 

Eldund  claims  to  have  found  in  the  secretions  of  both  gonorrhea  and 
chancroid  the  gonococcus  of  Neisser.  He  also  describes  mycelial  woven  fila- 
ments termed  E diopliyton  dictyoid&s.  This  parasite  he  also  claims  to  have 
seen  in  both  diseases.  So  far  as  it  goes,  this  is  confirmatory  of  the  correla- 
tion of  gonorrhea  and  chancroid. 

Looming  tip  clearly  from  the  midst  of  all  the  confusing  clinical  facts 
are  the  typic,  virulent  gonococcic  type  of  urethritis,  and  the  typic,  viru- 
lent, autoinoculaUe,  destructive  chancroidic  ulcer.  Each  more  than  likely 
represents  the  focal  point  of  cultivation  of  a  microbe  that  was  primarily 
innocuous.  Each,  moreover,  in  its  life-history,  responds  to  the  remorseless 
law  of  evolution  and  gradually  loses  its  specific  property  of  pathogenesis, 
until  its  germ  by  reversion  of  type  arrives  at  a  point  where  it  is  again  in- 
nocuous. Experiment  and  clinical  observation  alike  prove  this.  As  plainly 
as  the  clinical  specificity  of  typic  gonorrhea  and  chancroid,  stands  out  the 
incontrovertible  fact  that  the  local  venereal  diseases  have  their  origin  in  genital 
filth.    No  matter  how  it  operates,  filth  is  the  corner-stone  of  their  development. 


TAEIATIOX    OF    INFECTIOX.  273 

As  illustrative  of  the  clinical  evidence  in  support  of  the  evolutionary 
theory  of  the  origin  of  chancroid  the  following  cases  are  quite  pertinent: — 

Case  1. — Suppurative  adenitis  resembling  virulent  bubo,  following  balanitis  with 
ulceration :  A  delicate,  sickly  young  man  of  22  came  under  the  author's  care  suffering, 
as  he  supposed,  from  an  attack  of  gonorrhea.  He  had  a  very  long  prepuce,  which, 
through  ignorance,  was  rarely  retracted  and  cleansed.  Attacks  of  mild  inflammation 
had  occurred  several  times  before.  On  retraction  of  the  prepuce  the  glans  was  found 
to  be  covered  with  filthy  secretions  and  pus,  and  the  mucous  membrane  highly  in- 
flamed and  excoriated,  but  there  was  no  urethritis.  The  inflammation,  according  to 
the  history,  had  begun  three  or  four  days  after  a  suspicious  intercourse.  Although 
perfect  cleanliness  was  insisted  upon,  the  patient  was  careless,  and  it  was  several 
weeks  before  any  improvement  was  noticeable.  Meanwhile  several  small  ulcera- 
tions appeared  that  within  three  or  four  days  presented  all  the  characteristics  of 
chancroid.  Autoinoculation  was  successful,  but  the  resulting  ulcer  was  of  mild 
type.  The  author  examined  the  woman  from  whom  the  young  man  had  most 
certainly  contracted  the  disease,  if  venereal  in  character,  within  three  days  after 
the  appearance  of  the  balanitis,  and  found  her  healthy  save  for  a  chronic  endo- 
cervicitis  and  leucorrhea.  At  the  end  of  the  second  week  the  patient  developed  a 
large  inguinal  bubo,  that  \\'as  subsequently  opened,  the  pus  from  which  w^as  auto- 
inoculable,  but  did  not  produce  a  typic  lesion.  No  symptoms  of  syphilis  ever 
developed  and  the  balanitis  and  attendant  ulcerations  healed  in  a  few  weeks.  It 
was  nearly  three  months,  however,  before  the  bubo  was  completely  cicatrized. 

In  this  case  an  unhealthy  subject  with  a  tight  and  redundant  prepuce, 
beneath  which  irritation  was  constant,,  suffered  from  balanitis  from  time  to 
time.  'No  attention  was  paid  to  the  genital  toilet,  and  filthy  secretions,  both 
natural  and  pathologic,  accumulated  beneath  the  prepuce.  The  patient 
finally  exposed  himself  by  intercourse  with  a  woman  who,  although  prob- 
ably not  venereally  diseased,  was  uncleanly,  and  affected  by  uterine  disease 
with  irritating  discharge.  Some  of  this  discharge,  mixed  with  semen,  was 
deposited  beneath  the  patient's  prepuce,,  and  found  there  a  state  of  affairs 
most  favorable  for  germ-development.  Under  these  circumstances  of  heat, 
moisture,  filth,  and  local  irritation,  decomposition  occurred,  and  pathogenic 
microbes  ard  their  toxins  developed.  These  grew  more  virulent  from  day  to 
day,  and  ulceration  finally  occurred  at  several  points  upon  the  mucous  mem- 
brane. Glandular  infection  by  absorpt'on  from  the  affected  area  next  oc- 
curred, and  a  suppurating  bubo  appeared. 

Case  2. — Herpes,  bubo,  and  apparent  chancroid  from  infection  with  the  dis- 
charge from  a  subacute  endoeervicitis:  A  young  married  couple  were  referred  to 
the  author  by  their  family  physician,  who  supposed  them  to  be  syphilitic.  They 
had  been  married  two  weeks  and  had  indulged  in  sexual  intercourse  Avith  most 
unreasonable  frequency,  although,  as  the  wife  claimed,  the  attendant  pain  had  been 
severe,  and  had  within  a  few  days  necessitated  a  suspension  of  marital  relations. 
The  first  few  attempts  at  intercourse  had  been  attended  by  considerable  bleedino- 
and  left  the  ostium  vaginae  very  sore  and  painful.  Four  or  five  days  after  marriage 
a  leucorrhea,  by  which  she  had  been  annoyed  for  three  or  four  years,  became  verv 
profuse,  and  of  a  greenish  color.  At  the  same  time,  more  or  less  pelvic  pain  began, 
and  had  persisted,  although  its  severity  had  greatly  decreased.     Thinking  that  the 


274  CHAXCKOID. 

trouble  was  a  physiologic  consequence  of  her  new  circumstances,  she  paid  little 
attention  to  it.  At  the  end  of  the  first  week  the  husband  detected  some  small 
sores  upon  his  penis,  and  two  or  three  days  thereafter  inguinal  adenitis. 

Upon  close  questioning  the  author  concluded  that,  so  far  as  his  knowledge  of 
human  nature  permitted  him  to  judge,  he  had  to  deal  with  two  of  the  most  un- 
sophisticated persons  imaginable.  Subsequent  observation  served  to  confirm  the  be- 
lief that  they  were  not  only  innocent  of  any  wrong-doing  that  might  have  exposed 
one  or  the  other  of  them  to  venereal  infection,  but  that  they  had  not  the  slightest 
suspicion  that  such  an  idea  couldj  by  any  possibility,  enter  a  physician's  mind,  the 
gentleman  who  referred  them  to  the  author  having  kept  his  suspicions  to  himself. 

Upon  examination  the  husband  was  found  to  have  several  small  herpetic  ulcer- 
ations behind  the-  corona  glandis.  These  had  slightly -yellowish  bases  with  very  scanty 
secretion,  surrounded  by  a  narrow,  non-indurated  area  of  inflammation.  A  small 
apparently  simple  bubo  was  observed  in  the  right  groin. 

Upon  examining  the  wife,  the  ostium  vagime  was  found  to  be  swollen  and 
tender  and  marked  by  several  little  abrasions,  evidently  traumatic  in  character.  The 
remains  of  the  recently  ruptured  hymen  were  especially  sensitive  to  the  touch. 
There  was  no  vaginitis,  but  the  cervix  was  highly  inflamed,  and  from  the  os  was 
pouring  the  secretion  characteristic  of  an  inflamed  endometrium.  There  were  no 
evidences  of  syphilis  in  either  patient,  nor  has  a  single  suspicious  manifestation 
appeared  at  any  time  during  the  two  years  that  the  family  has  been  under  obser- 
vation. 

The  trouble  in  the  husband  disappeared  after  four  or  five  days'  careful  atten- 
tion. The  case  of  the  wife  did  not  progress  so  favorably,  a  circumstance  afterward 
explained  by  the  discovery  that  she  was  pregnant,  conception  having  occurred 
immediately  after  marriage.  At  the  end  of  the  second  week  after  coming  under 
observation  a  small  excoriation  at  the  fourchette  increased  in  size  and  became  ulcer- 
ated, and  in  a  few  days  the  resulting  ulcer  was  in  appearance  a  typic  chancroid. 
Autoinoculation  of  the  secretion  from  this  sore  produced  a  small,  apparently-typic 
ulcer.  The  inguinal  glands  upon  both  sides  became  slightly  swollen  and  tender,  but 
did  not  suppurate.  The  sore  healed  in  about  two  weeks,  the  inguinal  glands  mean- 
w'hile  returning  to  their  normal  condition.  Several  examinations  of  the  woman's 
secretions  for  gonococci  were  made,  but  with  a  negative  result. 

This  case  is  certainly  very  instructive.  The  trouble  appeared  first  in 
the  wife,  who  was  a  perfect  ignoramus  so  far  as  her  sexual  organs  were  con- 
cerned, and  who  certainly  had  never  had  intercourse  before  marriage.  The 
husband  had  no  urethritis  when  first  examined,  and  probably  did  not  have 
at  the  time  of  marriage,  else  some  evidences  of  it  would  have  been  present 
at  the  time  of  examination.  Sexual  excess  would  have  guaranteed  this.  It 
is  not  likely  that  he  attended  to  other  than  legitimate  duties  during  the  first 
two  weeks  after  marriage — men  rarely  do,  it  is  only  after  the  novelty  wears 
ofE  that  they  are  open  to  suspicion,  as  a  rule.  Moreover,  the  trouble  in  his 
case  was  simple  and  quickly  disappeared.  As  for  the  wife,  admitting  that 
she  was  a  rirgo  intacta  at  the  time  of  marriage,  it  is  scarcely  conceivable  that 
she  was  unfaithful  so  soon  afterward,  and  at  a  time  when  intercourse  was  so 
painful  to  her.  Then,  too,  her  trouble  was  primarily  not  of  a  character  to 
excite  suspicion,  as  was  shown  by  specular  examination.  The  apparent 
chancroid  appeared  some  days  after  the  husband's  trouble  disappeared,  and 
at  a  time  when  sexual  congress  was  well-nigh  impossible,  even  if  the  couple 


PECULIAEITIES    OF    CHAXCKOIDIC    IXrECTIOivT.  275 

had  been  inclined  to  disobey  instructions.  The  woman's  sore  was  situated 
at  a  point  where^,  if  the  disease  had  been  contracted  from  the  husband,  even 
admitting  tliat  he  had  venereal  ulcer,  it  would  have  appeared  within  a  few 
hours,  for  at  this  spot  an  abrasion  existed. 

Tkansmissibility  to  Animals. — Unlike  syphilis,  chancroid  is  trans- 
missible to  the  lower  animals  with  comparatively  little  difficulty.  The  suc- 
cessful inoculation  of  animals  was  first  accomplished  by  Auzias  de  Turenne 
in  1844.  In  1868  Eicordi  reported  a  case  of  virulent  bubo  in  the  rabbit, 
produced  by  inoculation  of  chancroidic  secretion.  Pus  from  this  bubo  was 
successfully  reinoculated  upon  healthy  animals. 

Syphilizatiok. — Auzias  was  also  the  first  to  demonstrate  that  suc- 
cessive inoculations  attenuate  chancroid.  He  was  not  himself  aware  of  such 
an  attenuation  however,  but  confounded  the  propter  with  the  post,  believ- 
ing that  the  final  impossibility  of  inoculating  the  same  animal  was  due  to 
gradual  loss  of  susceptibility.  As  Auzias  had  no  conception  of  the  existence 
of  two  varieties  of  venereal  ulcer,  he  concluded  from  his  experiments  that 
he  had  produced,  by  his  inoculations,  saturation  of  the  systems  of  the  ani- 
mals experimented  upon  with  the  virus  of  syphilis.  To  this  supposed  con- 
dition of  saturation  he  applied  the  term  "syphilization."  With  this  idea  in 
view,  he  drew  the  erroneous  conclusion  that  by  his  supposed  process  of 
syphilization  both  animals  and  man  could  be  made  insusceptible  to  syphilis. 
This  mistaken  and  fatuous  idea  has  been  perpetuated,  and  until  quite  re- 
cently had  still  a  few  learned  advocates.  The  late  Professor  Boeck,  of 
Christiana,  was  the  best-known  expounder  of  the  absurd  system  of  treat- 
ment of  syphilis  by  so-called  syphilization.  Apparently  beneficial  results 
bave  been  produced  by  the  treatment,  it  is  true,  but  they  are  due  to  the 
same  efi^ects  as  those  induced  by  pustulation  with  tartar  emetic,  the  benefit, 
such  as  it  is,  being  incidental  to  the  fatty  degeneration  caused  by  the  ex- 
tensive suppuration.  The  beneficial  effects  are  hardly  sufficiently  marked 
to  compensate  for  the  annoyance  and  suffering  incidental  to  the  treatment, 
in  comparison  with  which  syphilis  itself  is  a  mild  disease. 

Peculiarities  of  Chanceoidic  Infection. — The  infection  of  chan- 
croid being  practically  specific,  a  perfectly  characteristic  sore  can  only  be 
produced  primarily  by  inoculation  with  the  secretion  of  a  similarly-charac- 
teristic lesion. 

The  rule  that  "like  produces  like"  is  nowhere  more  applicable  than  in 
the  study  of  chancroid.  A  perfectly  typic  sore  produces  a  secretion  that 
is  capable  of  producing  a  sore  precisely  like  that  from  which  it  was  derived; 
while  the  secretion  of  a  sore  that  is  less  plainly  marked  and  destructive  is 
only  capable  of  producing  a  sore  of  a  comparatively  mild  type,  thus  showing 
that  the  severity  of  its  effects  depend  upon  the  degree  of  cultivation  of  the 
germ;  i.e.,  upon  its  stage  of  evolutionary  progression  or  reversion,  as  the 
case  may  be.  The  degree  of  autoinoculability  of  chancroid  varies  with  the 
degree  of  development  of  the  germ  in  every  case;  but  a  person  having  chan- 


276  CHAXCEOID. 

croid  is  fully  as  susceptible  to  infection  by  the  secretion  of  his  own  sore  as 
is  a  person  who  is  free  from  disease. 

Experiments  with  chancroidic  pus  have  shown  that  the  infections 
principle  is  still  active  after  desiccation^  or  even  freezing,  but  that  boiling 
or  the  admixture  of  strong  acids  or  alkalies  at  once  destroys  its  virulent 
properties.  It  is  said  that  decomposition  also  destroys  it;  but  this  is  doubt- 
ful. There  is  little,  if  an}^,  difference  in  the  virulency  of  the  secretion  of 
an  exposed  tyj)ic  chancroid  and  the  foul-smelling,  decomposed  pus  from 
concealed  cases  complicated  by  phimosis,  one  form  of  secretion  being  quite 
as  inoculable  as  the  other.  Gangrene — and,  it  has  been  claimed,  phagedena, 
— will  destroy  chancroid  infection.  This  is  not  true  in  all  cases,  however, 
as  autoinoculation  of  the  secretion  of  phagedenic  chancroid  is  usually  suc- 
cessful. When,  however,  the  phagedena  becomes  chronic,  the  virulency  of 
the  secretion  usually  disappears.  Bland  and  non-corrosive  menstrua  do  not 
modify  the  infection  of  chancroid.  It  is  quite  as  active  when  mixed  with 
semen,  milk,  blood,  or  healthy  urine  as  when  taken  alone,  provided  the  cir- 
cumstances of  its  inoculation  are  favorable. 

Xo  definite  quantity  of  the  infection-bearing  secretion  is  required  for 
inoculation.  Its  results  are  modified  by  the  extent  of  abraded  surface  upon 
which  it  is  inoculated,  the  resulting  chancroid  corresponding  in  size  and 
shape  Avith  the  inoculated  area. 

The  fallacious  practice  of  syphilization  has  taught  us  some  points 
wortlw  of  mention.  While  the  number  of  times  that  a  person  can  be  suc- 
cessfully inoculated  has  not  been  positively  shown,  it  has  been  proved  to  be 
considerable.  One  experimenter  inoculated  himself  nearly  three  thousand 
times  before  the  operation  failed.  The  infection  does  become  exhausted 
after  a  time — by  attenuation,  not  by  of  loss  of  susceptibilit}^  of  the  subject. 
Xo  permanent  period  of  immunity,  complete  or  partial,  is  attained  by  syph- 
ilization, and  with  fresh  secretion  from  a  different  individual  the  inocula- 
tions are  again  successful.  There  is,  therefore,  no  limit  to  the  number  of 
attacks  of  chancroid  that  one  individual  may  acquire. 

Some  regions  of  the  body  are  more  susceptible  to  chancroid  than  others. 
The  inner  aspect  of  the  thigh,  the  scrotum,  and  anus  are  very  susceptible; 
hence  we  often  see  these  parts  affected  by  numerous  chancroids,  accidentally 
caused  by  inoculation  from  a  penile  or  vulvar  sore.  The  face  is  not  very 
susceptible  to  inoculation. 

Eelatiye  Feequexcy  of  Chaxckoid. — The  frequency  of  chancroid 
varies  greatly  in  the  different  strata  of  society.  Being  essentially  a  filth  dis- 
ease, it  is  most  often  seen  among  the  lower  classes  and  those  who  consort 
with  them.  The  relative  frequency  of  chancroid  decreases  pari  passu  with 
advance  in  social  status.     Cleanliness  and  good  health  do  not  necessarilv 


^  This  is  contradicted  by  Taylor,  who  found  that  exposure  to  the  air  upon  glass 
plates  for  twenty-four  hours  destroyed  the  virulency  of  chancroidic  pus. 


METHODS    OF    IXFECTIOX.  *  277 

increase  morality,  but  tliey  certainly  lessen  the  frequency  of  venereal  affec- 
tions. In  dispensary  and  hospital  practice  chancroids  and  mixed  sores  are 
frequent,  while  in  the  better  class  of  private  practice  they  are  not  nearly 
so  numerous  as  syphilitic  chancres.  The  syphilitic  initial  lesion  is  of  trifling 
local  importance  and  rarely  recognized  by  the  prostitute;  but  chancroid 
produces  considerable  local  annoyance  and  is -likely  to  be  attended  by  sup- 
purating bubo.  Among  the  better  class  of  prostitutes,  therefore,  syphilis 
is  often  communicated  because  the  woman  is  herself  ignorant  of  her  dis- 
ease, while  chancroid  is  not  apt  to  be  so  communicated  for  the  simple  reason 
that  the  woman  is  too  solicitous  of  her  own  welfare  to  ply  her  trade  while 
suffering  with  so  troublesome  a  complaint.  The  lower-class  prostitute  not 
only  has  no  scruples  in  the  matter,  but,  nolens  volens,  she  must  continue  her 
trade  or  starve.  Then,  too,  she  often  becomes  inured  to  the  existence  of  a 
chronic  chancroid,  and  goes  on  spreading  the  noxious  disease  among  her 
patrons  who,  being  themselves  of  low  character  and  filthy  habits,  not  only 
contract  severe  chancroid,  but  act  as  carriers  of  the  disease.^ 

Methods  of  Infection. — It  is  fortunate  for  the  human  species  that 
the  venereal  diseases  are  not  infectious  in  the  sense  of  the  term  as  applied 
to  some  other  transmissible  diseases.  The  contagium  of  each  venereal  affec- 
tion is  a  material  substance,  and  not  a  miasm,  and,  as  a  consequence,  actual 
contact  of  the  poison-bearing  secretion  with  some  portion  of  the  body  is 
necessary  for  infection.     This  is  eminently  true  in  the  case  of  chancroid. 

As  contact  of  the  secretion  with  an  absorbent  surface  only  is  necessary 
to  inoculation,  it  is  obvious  that  there  are  several  ways  of  transmitting  the 
disease.  The  modes  of  contagion  are  broadly  classified  as  mediate  and  im- 
mediate. The  first  method  implies  the  contact  of  a  diseased  surface  with  a 
healthy  one.  This  may  occur  during  sexual  intercourse  or  by  handling 
the  diseased  surfaces  with  abraded  fingers.  Hang  nails  and  insignificant 
scratches  upon  the  hands  of  the  surgeon  are  often  the  sites  of  contagion. 
The  anxiety  consequent  upon  the  always  justifiable  doubt  as  to  the  possi- 
bility of  double  infection  is  one  of  the  worst  features  of  such  accidents. 

In  the  second  method  of  transmitting  chancroid  some  person  or  object 
intervenes  and  acts  as  a  carrier  of  infection.  Thus,  the  poison  may  be  con- 
veyed by  the  instruments  or  fingers  of  the  surgeon,  or  the  patient  with  chan- 
croid may  infect  himself  in  new  situations  by  scratching  himself  with  his 
finger-nails  after  having  handled  the  diseased  surface.  Autoinoculation  may 
occur  accidentally  through  a  healthy  surface  coming  in  contact  with  the  seat 
of  disease,  and  remaining  so  exposed  until  infection  occurs.  It  is  not  uncom- 
mon to  see  the  scrotum  and  thio'hs  covered  with  sores  contracted  in  this 


^  As  an  evidence  that  chancroid  is  essentially  a  disease  of  filth  and  faulty 
hygiene  may  be  advanced  the  fact  that  chancroid  is  growing  less  and  less  frequent 
with  advancing  civilization  and  increasing  sanitary  and  hygienic  knowledge.  Mauriac 
and  Taylor  both  claini  that  it  is  decreasing  in  frequency. 


278  CHAXCKOID. 

manner.  Patients  with  a  long  foreskin  who  have  chancroids  upon  the  glans 
penis  often  develop  by  autoinoculation  an  almost  exact  reproduction  of  the 
penile  chancroids  upon  the  contiguous  surfaces  of  the  prepuce.  Again,  the 
acrid  secretion  of  chancroid  ma}'  flow' over  healtl\y  tissues  and  finally  ex- 
coriate and  infect  them.  Where  there  is  a  long  foreskin  a  perfect  collar  of 
chancroids  is  often  found  about  the  preputial  orifice.  In  Avomen,  the  secre- 
tions from  the  vagina  and  vulva  are  directed  downward  over  the  perineum, 
and  anal  chancroids  are  apt  to  develop. 

A  very  interesting  method  of  transmission,  a  knowledge  of  which  some- 
times clears  up  the  obscurity  surrounding  the  manner  of  infection,  is  the 
following:  An  individual  with  a  long  prepuce  cohabits  with  a  woman  whose 
vagina  contains  the  infection  of  chancroid,  and  the  circumstances  not  being 
favorable  to  cleanliness,  or  being  negligent,  he  fails  to  wash  himself  and  the 
infection  remains  beneath  his  prepuce.  He  soon  afterward  has  intercourse 
with  another  and  healthy  woman,  deposits  the  infection  in  her  vagina,  by 
chance  washes  himself  and  goes  his  way.  Not  having  any  abrasions  upon 
his  penis  and  having  washed  himself  thoroughly  before  infection  could  oc- 
cur, he  escapes  chancroid.  The  healthy  woman  may  or  may  not  escape,  the 
danger  varying  with  the  toughness  of  her  vagina  and  the  length  of  time  that 
the  virus  remains  in  contact  with  the  mucous  membrane  of  that  structure. 
Shortly  after  individual  Xo.  1  has  finished  operations  with  female  No.  2, 
along  comes  an  unlucky  wight,  and,  having  intercourse  with  No.  2,  becomes 
inoculated  with  chancroid.  Should  the  woman  escape,  as  she  may  do,  and 
he  accuse  her  of  having  infected  him,  she  can  get  a  clean  bill  of  health  from 
any  physician.^ 

Physicians  are  not  infrequently  called  upon  to  examine  women  accused 
of  conveying  chancroid  and  quite  often  find  them  free  from  disease.  The 
author  has  had  this  experience  where  the  man  had  not  exposed  himself  with 
any  other  woman  than  the  one  suspected. 

It  is  often  easier  to  get  at  the  facts  in  these  cases  than  might  be  sup- 
posed, for  while  married  persons  and  dispensary  patients  ma}^,  from  various 
motives,  lie  about  their  venereal  afflictions,  the  young  blood  about  town  and 
the  professional  prostitute  are  candid  enough  regarding  the  wounds  re- 
ceived in  their  venereal  adventures.  It  is  a  matter  of  moral  indifference  to 
the  one,  for  she  regards  venereal  disease  as  her  hete  noire  only  when  it  neces- 
sitates a  cessation  of  business  for  a  time  or  an  expenditure  of  money  for  the 
doctor's  benefit:  as  for  the  other,  the  scars  are  honorable  among  his  class, 
being  evidence  of  his  very  rapid  existence. 

Abrasions  upon  the  mucous  membrane  or  skin  necessarily  facilitate  the 
inoculation  of  chancroid.  If  chancroidic  secretion  be  brought  in  contact 
with  a  raw  surface,  nothing  short  of  thorough  cauterization  will  prevent  in- 


^  In  two  separate  experiments  Cullerier  demonstrated  that  chancroidic  pus  may 
remain  in  contact  with  the  vagina  for  an  hour  or  more  without  infecting  it. 


LOCATIOX    OF    CHANCEOID.  '  279 

fection.  Primary  solutions  of  continuity  are,  however,  not  essential  to  in- 
oculation. 

In  the  case  of  a  man  with  a  long  prepuce  cohabiting  with  a  woman 
who  has  chancroid,  and  failing  to  wash  himself  thoroughly,  some  of  the 
infectious  secretion  remains  beneath  the  prepuce.  The  infection  is  espe- 
cially apt  to  be  localized  in  the  little  crypts  beside  the  frenum  preputii.  The 
mucous  membrane  being  thin  and  delicate  and  the  infectious  secretion  cor- 
rosive, and  the  circumstances  of  heat,  moisture,  and  continuous  local  irrita- 
tion prevailing,  maceration  of  the  epithelium  occurs  after  a  time,  followed 
by  absorption  and  local  infection. 

Similarly  the  chancroidic  poison  is  sometimes  rubbed  into  the  open 
mouth  of  a  minute  follicle  upon  the  surface  of  the  glans  penis;  maceration 
and  removal  of  epithelium  subsequentlj'  occurring,  impetiginous  chancroid 
develops.  In  the  same  Avay  syphilitic  chancre  is  sometimes  acquired.  The 
development  of  infection  in  such  cases  requires  some  little  time,  varying 
with  the  virulenc}^  of  the  virus,  and  the  thickness  of  the  epithelium.  The 
occurrence  of  such  cases  is  the  only  possible  explanation  of  the  difEerence 
in  the  rapidity  with  which  deliberately-inoculated  chancroid,  and  some  of 
those  contracted  during  sexual  intercourse,  appear.  The  occasional  cases  of 
greatly  prolonged  incubation  would  otherwise  be  difficult  to  comprehend. 

Location  of  Chaxckoid. — Chancroids  are  confined  to  a  rather  more 
limited  area  than  chancre.  They  are  rarely  found  excepting  about  the 
genital  organs.  The  exceptions  are  chiefly  due  to  inoculation  of  the  hands. 
Chancroid  about  the  head  and  face  is  so  rare  that  it  has  been  supposed  that 
these  regions  are  insusceptible  to  it.  Such  cases  have,  however,  been  re- 
ported, but  they  are  very  few  in  number.^  The  author  has  seen  one  case  of 
chancroid  of  the  face  due  to  a  patient's  scratching  a  pimple  after  handling 
his  genitals.  In  general,  the  different  areas  of  the  body  are  susceptible  to 
chancroid  in  direct  proportion  to  the  tenuity  of  their  tegumentary  covering 
and  the  facility  with  which  they  are  exposed  to  infection.  In  the  female 
chancroid  is  almost  always  located  about  the  vulva  and  ostium  vagince.  In 
this  location  the  mucous  membrane  is  very  thin,  and  there  are  numerous 
little  pockets  for  the  accumulation  of  noxious  secretions.  Here,  too,  the 
secretions  are  naturally  foul  and  prone  to  decomposition,  and  irritation  from 
extraneous  sources  is  most  marked.  There  is  little  doubt  that  many  cases 
of  chancroid  in  the  female  are  primarily  autogenetic.  The  infection-bear- 
ing secretion  is  elaborated  above,  but  the  vagina  is  quite  tough,  and  in  addi- 
tion has  become  acclimated,  so  to  speak,  by  the  time  the  evolved  infection 
has  arrived  at  its  acme  of  virulence.  As  it  trickles  down  over  the  external 
genitals,  however,  it  either  accumulates  in  the  numerous  little  crypts  there 


*  Although  usually  mild  when  it  occurs  in  this  situation.  Taylor  has  shown  that 
chancroid  about  the  head  may  be  quite  sevei'e.  Archives  (Brown-Sequard's),  Xo. 
5,  1873. 


280 


CHANCEOID. 


present,  and  after  maceration  of  the  epithelinm  produces  chancroid,  or  else 
it  immediately  infects  the  abrasions  that  so  often  exist  in  this  location.  The 
line  of  progression  often  extends  still  further,  the  tissues  about  the  anus 
becoming  infected.  Anal  chancroid  is  most  frecjuent  in  women  because  of 
the  trickling  doAvn  of  vaginal  discharge  when  they  are  in  the  recumbent 
posture.  This  gravitation  of  infectious  fluid  also  explains  why  the  four- 
chette  and  posterior  vulvar  commissure  are,  of  all  locations  upon  the  female 
genitals,  most  often  aifected  by  chancroid.  Intra-uterine  chancroids  have 
been  reported,  but  their  occurrence  is  problematic. 

Chancroids  of  the  anus  and  rectum  are  occasionally  contracted  through 


Fig.  94. — Multiple  chanc-roid  in  the  female. 


sexual  intercourse  by  perverts.  Anal  chancroid  from  sodomy  in  both  sexes 
has  been  seen.  The  author's  experience  in  such  cases  comprises  but  a  single 
instance:   that  of  a  woman,  who  freely  admitted  the  origin  of  the  disease. 

Chancroid  in  the  male  may  occur  anj^where  upon  the  penis,  but  is  most 
frequently  located  in  the  fossas  beside  the  frenum  preputii.  Discharges 
most  frequently  collect  in  this  situation  and  are  with  difficulty  washed  away. 
Chancroid  of  the  meatus  is  not  rare,  and  sores  involving  the  urethra  are 
occasionally  met  with.  Anal  and  rectal  chancroid  is  especially  rare  in  the 
male  and  always  justifies  a  suspicion  of  sexual  perversion. 

Scrotal  chancroids  occur  from  autoinoculation,  and  may  be  very  numer- 
ous.   The  thighs  may  be  inoculated  from  either  penile  or  scrotal  sores. 


CLINICAL    HISTOEY.      FORMS.  381 

Chancroid  may  be  inoculated  upon  growths  of  various  kinds,  and  has 
been  produced  upon  cancerous  neoplasia  and  elephantiasis.  It  ma}^  be 
grafted  upon  chancre.  There  is  a  possibility,  also,  that  some  mixed  sores  are 
instances  of  transformation  of  chancre  by  the  autogenesis  of  chancroidic 
infection  in  filthy  individuals.  Sores  are  certainly  met  with  in  which  ulcera- 
tion, the  secretion  of  which  is  autoinoculable,  appears  some  time  after  the 
chancre,  Avhere  the  patient  coidd  not  have  been  exposed  since  the  syphilis 
appeared.  This  certainly  harmonizes  with  the  evolutionary  theory  of  the 
origin  of  chancroid. 

Clinical  History. — The  history,  course,  and  symptoms  of  chancroid 
may  be  studied  with  most  facility  by  means  of  autoinoculated  sores.  In 
this  manner  the  phenomena  following  inoculation  may  be  observed  under 
the  most  favorable  circumstances.  The  best  point  for  inoculation  is  the 
inner  aspect  of  the  thigh  or  the  abdomen. 

The  results  of  autoinoculation  vary  but  little,  when  the  inoculated 
secretion  has  been  obtained  from  typic  chancroid;  thus  the  definiteness 
of  the  result  seems  to  depend  upon  the  degree  of  cultivation  of  the  infec- 
tion. The  lesions  consequent  upon  the  inoculation  of  all  morbid  secretions 
about  the  genitals  vary  from  a  slight  redness,  perhaps  followed  by  an  acnei- 
form  papule  or  pustule  or  herpetiform  ulceration,  to  severe  eroding  chan- 
croid.   Inoculation  may  be  performed  with  either  an  aseptic  lancet  or  needle. 

As  a  rule,  chancroids  resulting  from  accidental  autoinoculation  are  less 
severe  than  those  from  which  they  originated.  Gradually  decreasing  viru- 
lency  of  the  secretion  of  the  original  sore  will  explain  this.  In  some  cases, 
however,  secondary  chancroids  are  both  virulent  and  destructive. 

Within  twenty-four  hours  after  the  inoculation  of  the  secretion  of 
typic  chancroid,  a  reddish  areola  appears  about  the  spot;  by  the  second  day 
there  is  distinct  inflammation,  and  perhaps  pustulation  has  already  begun. 
When  ruptured,  this  pustule  is  found  to  surmount  a  small  circular  ulcera- 
tion that  increases  proportionately  in  depth  as  it  spreads.  When  it  has  at- 
tained about  the  size  of  a  dime,  it  usually  becomes  stationar}^  but  it  may 
increase  to  the  size  of  a  silver  quarter  or  involve  quite  an  area  of  tissue,  de- 
pending greatly  upon  the  constitution  of  the  patient.  The  promptitude  with 
which  chancroid  follows  inoculation  demonstrates  conclusively  that  the  dis- 
ease has  no  normal  period  of  incubation.  The  inflammatory  action  begins 
quite  as  promptly  as  when  other  irritating  infections  or  materials  are  intro- 
duced beneath  the  skin  or  mucous  membranes.  A  splinter  of  wood  would 
act  in  much  the  same  manner.  Inflammation  after  injury  is  an  effort  at 
repair,  but  it  requires  a  few  hours  for  the  tissues  to  react  to  the  injury.  It 
is,  of  course,  possible  that  the  immediate  effects  of  autoinoculation  are  due 
to  mixed  infection  and  simple  irritation,  -and  that  the  chancroidic  infection 
does  not  assert  itself  until  the  characteristic  ulceration  appears.  Pure 
culture  inoculations  may  one  day  settle  this  question. 

Forms  of  Chancroid.  —  When  contracted  during  sexual  intercourse 


282 


CHAXCEOID. 


chancroid  appears  in  several  different  ways  and  at  variable  periods.     The 
methods  of  its  appearance,  according  to  the  author's  experience,  are: — 

1.  An  abrasion  previousl}^  existing  or  produced  during  coitus  becomes 
inflamed,  and  begins  secreting  a  thin  muco-purulent  fluid.  Ulceration  next 
appears,  the  shape  of  the  ulcer  at  first  corresponding  to  that  of  the  abrasion, 
but  gradually  becoming  circular  or  oblong,  the  secretion  also  growing  more 
profuse  and  purulent.  If  there  are  numerous  abrasions  a  complete  collar  of 
small  ulcers  may  encircle  the  penis.     (Fig.  95.) 

2.  A  small  pre-existing  fissure  inflames  and  begins  secreting.  This 
deepens  rather  more  rapidly  than  it  spreads  laterally,  but  if  located  in  a 


Fig.  95. — Multiple  chancroids  in  the  male. 


natural  fold  of  the  skin  or  mucous  membrane  the  sore  extends  along  it  for 
a  considerable  distance,  often  involving  the  greater  part  of  the  circumfer- 
ence of  the  penis. 

3.  A  small  papule  with  a  reddened  base  first  appears,  but  in  a  day  or 
so  suppurates,  breaks  down,  and  forms  the  typic  ulcer. 

4.  A  small  pustule  is  first  noticed,  and  this  speedily  breaks  down,  re- 
vealing the  typic  ulcer.  This  and  the  preceding  form  have  been  termed 
the  follicular  chancroid.  The  terms  papulo-pustular  and  impetiginous 
chancroid  are,  however,  more  comprehensive. 

5.  A  pre-existing  herpes  or  simple  ulcer  becomes  infected  and  speedily 
takes  on  the  form  of  typic  chancroid. 


CHARACTEKISTICS.      TYPIC    COUESE.  283 

6.  Double  infection  results  in  the  so-called  mixed  chancre,  which  com- 
posite sore  presents  eventnall}^  the  combined  characteristics  of  chancre  and 
chancroid,  and  occurs  in  several  ways:  (a)  The  first  and  most  common  is 
where  the  poisons  are  received  simultaneously,  the  characteristic  chancroid 
appearing  first  and  subsequently  indurating,  (b)  Chancroid  is  acquired  first 
and  is  subsequently  inoculated  with  syphilis.  This  takes  the  same  course  as 
the  preceding  form,  save  that  the  time  elapsing  before  induration  is  longer, 
being  dependent  upon  the  period  in  the  life-history  of  the  soft  sore  at  which 
syphilitic  infection  occurs,  (c)  Chancre  is  transformed  by  autoinfection, 
and  presents  the  characters  of  a  mixed  sore. 

Chaeacteristics  of  the  Ulcer. — The  ulceration  in  typic  chancroid 
is  peculiar,  tending  to  a  circular  or  elliptic  form,  with  clearly-cut  or  un- 
dermined edges,  usually  steep  and  precipitous,  though  sometimes  everted'. 
The  sore  is  comparatively  deep,  especially  if  its  edges  be  undermined,  its 
floor  being  covered  with  a  grayish  or  yellowish  tenacious  deposit  resembling 
chamois-skin  that  has  been  chewed.  It  is  surrounded  by  a  reddish  inflam- 
matory areola  in  most  cases,  and  produces  a  tolerably  thick  yellowish  pus, 
which,  however,  changes  to  an  ichorous  or  sanious  character  if  the  sore  be 
irritated.  The  ulcer  is  not  painful  unless  it  is  irritated  or  becomes  phage- 
denic, in  which  case  the  pain  is  of  a  burning  character  and  may  become  very 
severe. 

Typic  Course. — If  not  disturbed,  chancroid  usually  runs  a  quite 
definite  course.  For  from  two  or  three  days  to  as  many  weeks  the  sore  in- 
creases in  size  without  change  in  its  peculiar  characteristics.  At  its  maxi- 
mum of  development  it  is  rarely  larger  than  a  dime,  although  it  may  be 
much  larger.  A  stationary  period  of  a  week  or  two  now  supervenes,  at  the 
end  of  which  repair  commences.  There  may  be  no  stationary  period:  i.e., 
repair  may  begin  at  any  time,  as  evidenced  by  improvement  in  the  character 
of  the  secretion  and  a  lessening  of  surrounding  inflammation.  "\^'lien  repair 
once  begins,  the  sore  sj^eedily  assumes  the  character  of  a  simple  ulcer, 
healthy  granulations  spring  up,  the  pus  becomes  healthy-looking,  and  cica- 
trization begins  at  the  periphery.  The  pus  is  autoinoculable  in  gradually- 
decreasing  degree  during  repair.^  About'  the  time  the  chancroid  is  nearly 
cicatrized  its  infectious  properties  are  usually  lost.  The  self-limitation  of 
chancroid  under  favorable  circumstances  is  another  evidence  of  its  spon- 
taneous origin. 

The  environment  of  chancroid,  when  kept  clean,  is  different  from  that 
in  which  the  infection  originates,  and  the  life-history  of  the  sore  is  neces- 
sarily different.     "When  the  conditions  are  unhygienic  the  chancroid  is  not 


^  It  was  long  supposed  that  when  repair  of  chancroid  sets  in  its  secretion  in- 
variably ceases  to  be  poisonous.  It  undoubtedly  does  lose  much  of  its  viruleney,  but, 
as  Fournier  has  shown,  characteristic  sores  may  sometimes  be  produced  by  tUe  in- 
oculation of  the  discharg-e  from  chancroids  that  are  nearlv  healed. 


284 


CHAXCEOID. 


only  not  self-limited,  but  may  be  continued  indefinite  j,  as  is  seen  in  cer- 
tain chronic  chancroids  in  both  men  and  women. 

Chancroid  may  lose  its  virulence  as  a  consequence  of  gangrene,  or  may 
be  transformed  into  chronic  nicer,  simple  or  infections,  of  indefinite  dura- 
tion. The  latter  is  occasionally  seen  in  the  form  of  old  chronic  chancroids 
about  the  anus  or  on  the  vulva  or  vagina  in  old  prostitutes,  in  whom  more 
or  less  irritation  is  constant. 

CiCATEix. — The  cicatrix  of  chancroid  varies  in  size  and  appearance  ac- 
cording to  the  size  and  location  of  the  sore.     In  some  slight  cases  it  disap- 


Fiff.  96. — Chronic  chancroid  of  rioht  labia. 


pears  entirely,  but  in  the  majority  of  instances  it  is  permanent.     It  is  usu- 
ally white,  and  presents  no  characteristic  features. 

Peogxosis. — When  chancroid  runs  a  normal  and  self-limited  course  it 
is  an  affair  of  comparative  insignificance.  Unfortunately,  however,  it  does 
not  always  act  so  benignantly.  It  sometimes  undergoes  transformation  by 
gangrene,  inflammation,  phagedena,  coalition  with  other  sores,  or  serpigi- 
nous ulceration.  In  the  latter  event  it  is  very  apt  to  become  chronic,  ad- 
vanciiig  upon  one  side  while  healing  upon  the  other,  such  cases  being  espe- 
cially obstinate  and  discouraging. 


NUMBER    OF    SORES.       EXTEXT.       DITRATIOX.  285 

Number  of  Sores. — The  number  of  chancroids  has  no  arbitrar}^  limit, 
and,  as  already  noted,  a  large  number  ma}^  be  inoculated  upon  the  same  in- 
dividual. Chancroid  ma}^  remain  single  throughout  or  may  become  numer- 
ously multiple  through  autoinoculation;  thus,  the  same  individual  may 
have  chancroids  upon  the  penis,  foreskin,  scrotum,  anus,  and  inner  aspect  of 
the  thighs. 

Extent. — Chancroids  vary  in  extent,  being  usually  of  very  moderate 
size.  In  exceptional  cases,  however,  they  invade  a  very  large  area  of  surface. 
Thus,  they  may  vary  in  size  from  the  dimensions  of  a  pin's  head  to  those 


Fig.  97. — Extensive  destruction  of  the  genitals,  perineum,  and  ischio-rectal 
fossas  from  chancroid  in  an  old  syphilitic.  Showing  rectum  exposed. 
(After  T.  A.  Davis.) 


terrible  phagedenic  affairs  that  sometimes  lay.  bare  quite  an  extent  of  the 
thigh,  testes,  groin,  or  abdominal  walls. 

Duration. — The  duration  of  chancroid,  when  simple  and  untreated, 
is  four  or  five  weeks  and  upward,  depending  greatly  upon  the  size  of  the 
sore  and  its  location,  some  situations  being  more  exposed  to  irritation  than 
others.  On  this  account,  chancroids  of  the  meatus,  urethra,  anus,  rectum, 
and  posterior  vulvar  commissure  are  apt  to  become  chronic,  and  their  bases 
hardened  and  infiltrated.  The  causes  of  prolonged  duration  of  chancroid 
may  be  summed  up  as: — 


286  CHAXCKOID. 

1.  Exposure  to  heat,  moisture,  filth,  and  contact  of  irritating  and  acrid 
discharges. 

2.  Cachectic  constitutional  conditions,  of  which  chronic  inehriety, 
syphilis,  struma,  and  phthisis  are  most  important. 

3.  Friction  induced  by  sexual  intercourse  or  excessive  movement.  It 
is  lack  of  rest  as  much  as  anj^thing  that;  prolongs  anal  chancroid. 

■±.  Debility  from  insufficient  or  improper  food,  bad  air,  and  other  un- 
hygienic conditions. 

5.  Intemperance  in  eating  and  drinking. 

6.  Improper  treatment  at  the  hands  of  the  patient  and  his  friends, 
drug-clerks,  or  inexperienced  physicians. 

From  any  of  these  causes,  and  often  without  any  apparent  cause,  chan- 
croid may  relapse  when  it  seems  to  be  healing  nicely.  This  is  especially  apt 
to  occur  in  chancroids  that  have  been  phagedenic  or  gangrenous.  Often- 
times a  chancroid  that  is  progressing  favorably  will  be  suddenly  attacked  by 
phagedena  and  spread  quite  rapidly. 

Complications  of  Chanceoid. — The  principal  complications  to  which 
chancroid  is  liable  are:  1.  Inflammation, — simple  cr  erysipelatous.  2.  Lym- 
phitis,— simple,  suppurative,  or  specific.  3.  Phimosis  and  paraphimosis.  4. 
Venereal  vegetations  or  vegetating  papillomata.  5.  Gangrene.  6.  Serpig- 
inous ulceration.  7.  Phagedena.  8.  Simple  adenitis.  9.  Virulent  ade- 
nitis.    10.  Syphilis.     11.    Urethritis, — simple  or  gonococcic. 

Inflammation. — Inflammation  of  chancroid  is  often  met  with;  the  in- 
fection is  a  mixed  one,  and  sources  of  irritation  are  numerous  and  constant. 

Etiology. — The  causes  of  inflammation  are:  1.  Constitutional  predis- 
position or  cachexia.  As  Lloyd  expresses  it,  the  patient  may  be  a  "suppu- 
rater.'*'  2.  Uncleanliness.  3.  Phimosis  or  paraphimosis.  4.  Sexual  inter- 
course. 5.  The  injudicious  application  of  caustic  or  irritant  drugs.  6.  In- 
temperance. 7.  Sepsis  from  pus  or  toxin  infection  often  superinduced  by 
the  foregoing  causes. 

Chancroids  beneath  a  tight  prepuce  are  especially  apt  to  inflame,  often 
producing  phimosis  or  paraphimosis.  When  the  prepuce  is  constricted  and 
inflamed  it  becomes  enormously  swollen  and  infiltrated.  The  edema  is  often 
so  extensive  that  the  part  is  translucent.  Clinically,  the  condition  is  really 
lymphangitis,  and  it  is  but  a  step  from  this  to  classic  erysipelas.  In  this 
condition  gangrene  of  the  prepuce,  or  perhaps  the  glans,  is  apt  to  occur 
from  circulatory  obstruction.  Preputial  gangrene  in  phimosis  usually  be- 
gins just  over  the  superior  surface  of  the  glans.  In  all  cases  of  phimosis 
the  secretions  are  pent  up,  thus  predisposing  to  gangrene,  erj^sipelas,  phage- 
dena, and  serpiginous  ulceration.  When  true  erysipelatous  infection  occurs, 
severe  and  dangerous  sloughing  may  ensue.  The  scrotum  may  become  in- 
volved, and  death  from  exhaustion,  pyemia,  or  septemia  is  possible. 

Pus  confined  beneath  the  prepuce  may  burrow  in  various  directions, 
forming  chronic  sinuses  and  fistulas,  possibly  undermining  the  entire  penile 


COMPLICATIONS    OF    CHAXCEOID.  287 

integument.  If  the  patient  be  debilitated  or  cachectic — and  this  is  espe- 
cially true  of  hard  drinkers — the  inflammation  may  be  indefinitely  pro- 
longed. Inflammation  of  the  lymphatics  may  take  a  suppurative  course 
and  cause  considerable  destruction  of  tissue. 

A  frequent  element  in  the  causation  of  inflammation  in  chancroids  is 
the  application  of  silver  nitrate,  copper  sulphate,  or  some  other  superficial 
caustic  or  irritant  to  the  lesion.  Patients  often  do  this  themselves  or  em- 
ploy irresponsible  persons  to  do  it  for  them.  Ointments  are  often  applied 
and  allowed  to  become  rancid.  The  results  of  this  ill-advised  therapy  are 
not  only  painful,  but  greatly  confuse  the  diagnosis. 

When  inflammation  begins  the  chancroid  becomes  greatly  transformed. 
It  becomes  excessively  painful,  the  pain  being  of  a  burning  character;  the 
color  of  the  lesion  changes  to  an  angry  red  or  livid  hue,  and  its  secretion 
becomes  scanty,  thin,  and  sanious  or  ichorous.  The  ulceration  now  extends 
rapidly,  and,  if  suppurating  inguinal  adenitis  has  not  already  occurred,  it 
is  quite  likely  to  supervene. 

The  changes  in  the  base  of  the  chancroid  are  the  most  important  re- 
sults of  inflammation,  and  usually  confuse  the  diagnosis.  Normally,  the 
base  of  the  ulcer  is  soft  or,  at  most,  slightly  boggy.  When  inflamed,  how- 
ever, it  speedily  becomes  indurated  to  a  greater  or  less  extent.  Induration 
may  also  occur  in  any  genital  lesion,  especially  in  balanitic  or  herpetic  ulcers, 
but  rarely  to  such  a  marked  degree — sufficiently  marked,  however,  to  render 
the  diagnosis  more  or  less  obscUre.  This  induration  is  often  mistaken  for 
the  initial  lesion  of  syphilis.  As  a  rule,  there  are  quite  pronounced  differ- 
ences between  indurated  chancroid  and  true  chancrous  induration.^ 

In  lieu  of  the  hard,  abruptly-defined,  cartilaginous  induration  found 
in  chancre,  that  of  inflamed  chancroid  is  softer,  boggy  to  the  feel,  is  not 
circumscribed,  but  shades  off  into  the  surrounding  tissues,  and  may  be  con- 
siderably reduced  in  size  by  squeezing  out  the  infiltration  with  the  fingers. 
It  is  quite  painful  to  the  touch:  a  point  in  which  it  differs  markedly  from 
the  uncomplicated  initial  syphilitic  lesion. 

The  ulceration  is  always  primary,  and  the  induration  secondary  in 
typic  soft  sores,  while  in  chancre  the  reverse  usually  holds  true.  Too  much 
stress  must  not  be  laid  upon  this  difference,  because  mixed  infection  or 
transformation  of  hard  sores  may  make  this  clinical  fact  of  little  value. 

Chancroid  sometimes  presents  exuberant  granulations.  Erichsen  de- 
scribes this  condition  as  "fungating  sore."^ 

ISTotwithstanding  what  has  been  said,  the   difficulties   of   differential 


^  It  is  a  clinical  fact  which  the  author  believes  most  surgeons  have  observed, 
and  on  reflection  will  substantiate,  that  all  lesions  about  the  genitals  have  a  most 
peculiar  tendency  to  obstinate  ulceration  and  to  induration.  The  influence  of  gravity 
on  the  circulation,  the  abundance  of  fine  lymphatics,  and  the  looseness  of  the  areolar 
tissue  probably  account  for  this. 

"  "Science  and  Art  of  Surgery." 


388  CHANCROID. 

diagnosis  are  often  very  great.  In  quite  a  proportion  of  cases  only  the  sub- 
sequent history  permits  a  correct  conclusion.  Considering  the  sources  of 
continued  and  severe  irritation  that  exist  in  most  cases  of  chancroid;,  and 
the  fact  that  clinically  it  is  a  mixed  infection,  such  perplexing  cases  are  in 
nowise  remarkable. 

To  impress  this  point  more  fully  the  following  cases  are  presented: — 

Case  1. — A  young  man  consulted  his  physician  for  what  was  claimed  to  be  his 
first  attack  of  venereal  disease.  He  stated  that  about  two  weeks  after  suspicious 
intercourse  he  developed  a  small  ulcer  upon  the  glans  penis.  This  was  pronounced 
syphilitic  and  cauterized  with  silver  nitrate.  The  case  finally  came  into  the  author's 
hands.  There  was  a  scantily  secreting,  slightly  painful,  and  apparently  typically 
indurated  sore  just  back  of  the  corona  glandis.  The  induration  was  cartilaginous  to 
the  feel,  and  quite  abrupt,  being  about  the  size  of  a  hazel-nut.  The  inguinal  glands 
were  moderately  enlarged  and  quite  hard,  but  not  especially  tender.  These  features 
of  the  case,  in  combination  with  the  alleged  prolonged  "period  of  incubation  led 
the  author  to  suspect  syphilis.  Diagnosis,  however,  was  reserved.  The  patient  being 
anxious  to  avoid  eruptions  and  convinced  that  he  had  syphilis,  became  restless  and 
sought  other  counsel.  A  full  mercurial  course  was  begun  by  the  new  medical 
adviser.  After  about  eight  months'  careful  treatment,  the  patient  returned,  stating 
that  he  had  "another  dose."  On  examination,  another  sore  was  found  at  the  site  of 
the  first  one  and  of  essentially  the  same  physical  characters.  This  sore  was  followed 
by  a  moderately  severe  and  typic  course  of  secondary  syphilis. 

Case  2.- — This  case  was  similar  to  the  preceding,  with  the  exception  that  copper 
sulphate  was  applied  by  the  patient  himself.  A  suppurating  bubo  formed,  leading 
the  physician  in  charge  to  consider  the  case  one  of  double  infection.  Mercurials 
were  given,  and,  as  a  slight  sore  throat  with  small  eroded  patcties  in  the  mouth 
soon  afterward  developed,  this  treatment  Was  continued  for  a  year.  At  the  end 
of  this  time  there  developed,  three  weeks  after  exposure,  a  typic  Hunteriau  chancre 
that  was  followed  by  a  quite  severe  course  of  secondai-y  lesions.  When  the  genuine 
chancre  appeared  the  ease  came  under  the  author's  care. 

In  both  of  the  foregoing  cases  a  serious,  but  instructive,  mistake  was 
made.  Such  errors  are,  however,  only  too  frequent,  and  should  warn  the 
surgeon  against  a  speedy  and  arbitrary  diagnosis. 

PJiimosis  and  Paraphimosis. — These  conditions  are  most  often  asso- 
ciated in  chancroid,  and  are  frequently  due  to  inflammation.  Phimosis 
may  be  congenital  or  inflammatory,  and  acts  in  two  waj^s,  viz.:  (1)  by  pen- 
ning up  foul  secretions,  thus  preventing  free  drainage  and  antisepsis,  and 
(2)  by  cutting  off  the  circulation  to  a  certain  extent.  Paraphimosis  causes 
gangrene  just  as  a  string  would  do  if  tied  behind  the  corona  glandis;  fortu- 
nately, however,  the  resulting  tissue-necrosis  often  first  attacks  the  con- 
stricting ring  of  prepuce  itself,  destroying  its  continuity  and  relieving  the 
constriction.  In  this  way  the  glans  penis  is  probably  sometimes  saved  from 
destruction. 

Gangrene. — This  complication  of  genital  disease  is  not  necessarily  lim- 
ited to  chancroid,  but  may  occur  with  any  lesion  of  these  parts.  Herpes, 
balanitis,  simple  phimosis  and  paraphimosis,  simple  ulceration,  and  chancre 
are  each  occasionally  attended  bv  sfanOTene. 


COMPLICATIONS    OF    CHANCKOID.  289 

Gangrene  of  genital  lesions  occurs  in  two  forms,  viz.:  (1)  circum- 
scribed or  self-limiting;  (2)  progressive  or  phagedenic.  In  addition  to 
mechanic  causes,  gangrene  is  predisposed  to  by  alcoholism,  old  age,  debility, 
and  syphilis.  The  first  form  is  generally  secondary  to  acute  inflammation, 
as  in  phimosis  and  paraphimosis.  The  tissue-tension  is  extreme  in  these 
cases  and  the  vitality  of  the  tissues  becomes  so  impaired  that  gangrene  comes 
on  very  suddenly.  In  the  more  fortunate  cases,  the  prepuce  sloughs  and  the 
glans  protrudes  through  the  "button-hole"  thus  formed  upon  the  dorsum, 
•or  else  the  entire  prepuce  sloughs,  constituting  a  neat,  spontaneous  circum- 
cision that  leaves  the  organ  in  better  shape  than  before.  When  the  prepuce 
sloughs  only  partially  the  remaining  tissue  sometimes  becomes  dense  and 
infiltrated.  This  variety  of  gangrene  rarely  complicates  chancroid  unless  it 
be  subpreputial,  and  is  the  least  dangerous  form  of  the  affection.  After  the 
separation  of  the  slough  a  clean,  healthy,  granulating  surface  is  left,  the 
secretion  of  which  is  not  inoculable  save  as  simple  pus-infection. 

When  the  inflammation  and  disturbance  of  the  circulation  are  not 
severe  enough  to  destroy  the  tissues  en  masse,  the  phagedenic  form  of  gan- 
grene supervenes.  In  this  variety  sloughing  slowly  progresses,  or  a  suc- 
cession of  sloughs  form  and  are  cast  off  as  the  ulcer  gradually  increases  in 
size.  Sometimes  this  increase  is  very  rapid  and  destructive.  Wliether  a 
special  infection  is  the  fons  origo  in  such  cases  is  still  sub  judice. 

In  all  forms  of  genital  gangrene  the  pain  is  severe,  and  of  a  burning  or 
stinging  character,  this  being  most  marked  in  the  phagedenic  variety. 

The  slough  in  the  circumscribed  form  varies  in  color  from  a  dirty 
brown  to  a  deep  black,  while  in  the  phagedenic  form  it  is  of  a  grayish  or 
greenish  hue.  The  secretion  in  gangrene  is  a  fetid,  thin  sanies  or  ichor 
that  emits  a  stench  so  foul  that  the  odor  of  the  dissecting-room  is  agreeable 
by  comparison. 

The  constitutional  symptoms  are  usually  more  or  less  fever,  great  de- 
bility, and  in  fatal  cases  a  somewhat  characteristic  typhoid  state.  The 
]3robabilities  are  that  in  many  of  the  cases  the  constitutional  condition  is 
one  of  sapremic  or  toxin  infection  secondary  to  the  gangrenous  process. 
These  constitutional  disturbances  are  important,  for  they  not  only  deter- 
mine certain  therapeutic  indications,  but  they  are  the  type  of  general  mani- 
festations present  in  gangrene  wherever  situated. 

Phagedena. — True  phagedenic  chancroid  is,  to  the  author's  mind,  the 
nearest  possible  approach  to  sloughing  phagedena  or  classic  hospital  gan- 
grene, and  should  be  treated  upon  the  same  principles.  It  differs  from  the 
latter  in  that  it  does  not  usually  present  a  distinct  slough.  Occasionally, 
however,  it  merges  into  ordinary  gangrene.  In  such  cases  small  adherent 
sloughs  ex;ist — gangrenous  phagedena.  Phagedena,  properly  speaking,  is 
rapid  ulceration  or  molecular  gangrene,  probably  due  to  streptococcic,  in- 
fection, and  may  attack  ulcers  of  all  kinds,  not  being  limited  to  chancroid. 
Although  the  ulceration  in  phagedenic  chancroid  extends  very  rapidly,  it 


290  CHANCKOID. 

retains  its  typic  characters,  and,  excepting  in  a  few  very  chronic  cases,  its 
secretion  is  autoinocnlable  and  virulent  throughout  its  course. 

Phagedena  may  be  either  superficial  or  deep,  its  destructiveness  varying 
accordingly.  Its  advance  is  not  especially  rapid  and  may  be  serpiginous, 
advancing  in  a  devious  manner  and  healing  upon  one  side  while  progressing 
upon  the  other.  Cellular  tissue  seems  to  be  especially  susceptible  to  the  in- 
fection. It  often  dissects  up  the  entire  integument  of  the  penis  or  traverses 
the  course  of  vessels  and  nerves,  perhaps  dissecting  them  out  quite  cleanly. 
The  superficial  form  of  phagedena  may  be  obstructed  in  its  progress  by 
fascia  or  fibrous  structures,  but  the  deep  form  is  no  respecter  of  tissues  and 
consumes  them  all  indifEerently.^ 

Either  simple  or  virulent  bubo  may  be  attacked  by  phagedena,  the 
virulent  form  being  especially  susceptible.  It  has  been  claimed  that  only 
virulent  buboes  are  subject  to  it.  The  author  has,  however,  seen  a  bubo  in 
process  of  repair  that  had  lost  its  virulent  properties  and  well-nigh  healed 
by  healthy  granulation  and  cicatrization  suddenly  become  phagedenic,  and 
not  only  lay  the  abdominal  muscles  bare  over  a  large  area,  but  actually 
invade  their  structure  to  a  considerable  depth. 

The  serpiginous  form  of  phagedena  may  advance  very  slowly,  and, 
becoming  chronic,  lay  bare  the  penis  and  perhaps  the  testicles,  sometimes 
healing  behind  as  it  advances,  and  sometimes  not.  In  discussing  this  form 
of  chancroid,  the  author  recalls  a  striking  case  that  was  for  a  time  under 
his  care  in  the  New  York  Charity  Hospital: — 

Case. — The  phagedenic  process  involved  the  penis  and  scrotum,  and  before  it 
was  finally  checked  had  invaded  the  groins  and  loAver  portion  of  the  abdomen.  The 
parts  affected  were  entirely  denuded  of  integument,  and,  in  great  part,  of  cellular 
tissue.  When  the  disease  was  finally  checked — more  by  Nature's  own  efforts  than  the 
result  of  treatment^ — it  Avas  hoped  that  healing  would  occur,  but,  instead,  the  process 
remained  stationary,  and  no  form  of  treatment  seemed  to  benefit  it  in  the  least. 
The  case  was  in  the  hospital  for  several  years,  during  which  time  every  form  of 
"regular"  torture  was  applied  that  ingenious  and  enterprising  house  and  visiting 
surgeons  could  devise.  He  finally  drifted  into  the  hands  of  the  surgeons  at  the 
homeopathic  hospital,  but  their  treatment  met  with  no  more  successful  result  than 
had  ours,  and  he  finally  died,  worn  out  with  much  suffering  and  more  treatment. 

There  is  a  ease  of  serpiginous  phagedena  related  by  Fournier  that  had 
existed  for  fourteen  years,  at  the  end  of  which  time  there  was  still  an  ulcer 
at  the  knee,  the  lesion  having  healed  behind  as  it  progressed.  This  case 
passed  through  the  hands  of  M.  Eicord;  so  that  it  is  safe  to  assume  that  its 
formidable  character  was  not  due  to  lack  of  proper^  treatment.    Chancroids 


^Wallace  divides  phagedenic  chancre  into  three  varieties  Aaz. :  (1)  that  without 
slough;  (2)  that  with  white  slough;  (3)  that  with  black  slough.  This  is  certainly 
simple  enough,  but  too  arbitrary,  and  scarcely  borne  out  clinically. 

-  "Nouveau  Diet,  de  medecine  et  de  chir.  prat.,"  Paris,  vol.  iii,  p.  771. 


COMPLICATIONS    OF    CHANCKOID.  291 

of  this  character  may  appear  to  be  in  process  of  repair,  .and  suddenly  with- 
out any  apparent  cause  relapse  and  continue  their  work  of  destruction. 

There  is  one  form  of  chronic  phagedenic  chancroid  that  merits  special 
consideration.  This  occurs  in  the  vagina  and  vulva  of  broken-down  pros- 
titutes, often  involving  not  only  these  parts,  but  the  anus  and  a  considerable 
extent  of  the  surrounding  tissues.  As  a  result  of  friction,  and  local  irrita- 
tion from  the  contact  of  foul  secretions,  these  sores  become  chronic.  Their 
bases  become  indurated  and  hyperplasic,  quite  extensive  proliferation  of 
tissue  resulting,  thus  giving  the  lesions  an  elevated  appearance.  Specificity 
is  lost  and  secretion  is  quite  scanty,  the  eroded  surface  being  covered  with 
a  more  or  less  tenacious  yellowish  coating  of  pus  and  tissue  detritus.  These 
sores  show  no  tendency  to  repair,  and  are  about  as  terrible  an  affliction  as 
can  be  imagined.  A  fatal  result  is  inevitable  in  such  cases,  but,  unfortu- 
nately, it  is  only  after  months  or  even  years  of  suffering  that  death  from 
exhaustion  closes  the  scene. ^ 

The  author  recalls  several  similar  cases  from  hospital  practice: — 

Case  1. — A  girl,  17  years  old,  had  been  a  prostitute  for  several  years,  having 
commenced  at  a  very  tender  age.  Some  months  before  entering  the  hospital  she 
contracted  chancroid.  This  became  phagedenic  and  Avas  followed  by  bilateral  phage- 
denic bubo.  The  sores  originally  involved  the  vulva  and  vagina,  but  had  invaded 
the  groins  and  become  fused  with  the  buboes  upon  either  side,  forming  one  huge 
area  of  chronic  ulceration.  The  surface  had  become  hyperplasic,  giving  it  an  elevated 
contour.    The  unhealthy  granulations  were  covered  with  a  tenacious  pulpy  secretion. 

Every  conceivable  method  of  treatment  was  tried  in  this  case,  even  the  actual 
cautery  being  freely  employed,  but  without  avail.  The  poor  creature  finally  died, 
worn  out  by  pain  and  exhaustion. 

Case  2. — This  case  was  one  of  chronic  chancroid  in  a  pregnant  woman.  The 
entire  vulva  was  involved,  and  from  the  diseased  surfaces  frequent  hemorrhages 
occurred  as  a  consequence  of  the  great  congestion  of  the  sexual  organs  incidental  to 
pregnancy.  Nothing  in  the  way  of  treatment  proved  of  benefit,  and  labor  was  looked 
forward  to  with  much  apprehension.  When  the  labor  finally  did  occur,  forceps  were 
found  necessary.  The  consequent  laceration  of  the  friable  diseased  tissues  was  con- 
siderable and  the  prospect  for  recovery  seemed  very  dubious.  However,  the  woman 
not  only  recovered,  but  the  chancroids  healed  perfectly  within  three  weeks,  showing 
plainly  that  their  chronicity  had  depended  mainly  upon  the  congestion  of  the  parts 
due  to  pregnancy.^ 

The  cases  of  chronic  chancroid  that  have  Just  been  considered  are 
termed  by  some  authors  "lupoid  ulceration,"  or  "lupus  of  the  vulva."  They 
are,  however,  not  allied  to  lupus,  but,  like  that  disease,  they  probably  have 

^  This  form  of  ulceration  Avas  carefully  described  by  Costilhes  and  Bois  de  Loury 
in  1845.  See  also  Huguier,  "Esthiomene,"  1849;  Taylor,  New  York  Medical  Journal, 
January  4,  1890;  and  Lydston,  "Transactions  of  the  Chicago  Academy  of  Medicine," 
1892. 

^Apparently  simple  chancroids  with  a  marked  tendency  to  bleeding  are  occa- 
sionally seen  in  both  men  and  women.  These  "hemorrhagic  chancroids"  are  due  to 
local  irritation  and  congestion  from  sexual  excitement,  often  combined  with  alcoholic 
indulgence. 


292  CHANCKOID. 

underlying  their  causation  some  as  yet  undetermined  constitutional  predis- 
position.   A  syphilitic  constitution  is  often  the  underlying  cause. 

Etiology  of  Phagedena. — It  is  a  peculiar  fact  that  some  persons  de- 
velop phagedena,  while  others,  who  have  contracted  the  disease  perhaps 
from  the  same  woman,  and  who,  moreover,  are  hygienically  situated  pre- 
cisely like  the  victims  of  phagedena,  escape  it.  As  compared  with  the  total 
number  of  cases  of  chancroid,  phagedena  is  exceptionally  seen;  hence  when 
it  does  appear  a  special  cause  seems  plausible.  Whatever  the  exciting  cause 
may  be,  there  will  usually  be  found  underl3dng  phagedena  that  mysterious 
something  which  will  always  prevent  medicine  from  becoming  an  exact 
science,  viz.:  individual  predisposition,  or  idiosyncrasy.  Persons  so  pre- 
disposed may  have  numerous  attacks  of  chancroid,  and  phagedena  with 
each  and  every  one,  and  this,  too,  when  they  appear  ]3erfectly  robust  and 
healthy,  and  their  habits  and  manner  of  living  are  hygienically  irreproach- 
able. There  is  probably  no  such  thing  as  a  complicating  specific  infection 
as  an  explanation  for  the  occurrence  of  phagedena,  for  it  is  an  established 
fact  that  a  phagedenic  sore  may  be  acquired  by  confrontation  with  a  simple 
chancroid  and  vice  versa.  Again,  if  we  autoinoculate  the  virus  of  a  phage- 
denic chancroid,  phagedena  will  result  in  the  majority  of  cases,  while  if  we 
heteroinoculate  the  same  poison — i.e.,  if  we  transfer  it  to  another  individual 
— simple  chancroid  generally  results,  although  not  so  uniformly  as  when  the 
virus  of  a  simple  sore  is  employed.^ 

So  far  as  researches  have  gone,  superimposed  streptococcic  infection  is 
the  most  likely  point  of  departure  for  phagedena.  Koch  discovered  an  or- 
ganism, probably  allied  to  the  streptococcus  erysipelatosus,  to  which  hospital 
gangrene  is  probably  due.  A  variation  of  the  same  germ  ma}^  be  the  cause  of 
genital  phagedena.  The  author  is  inclined  to  attribute  the  tissue-destruc- 
tion in  phagedena  to  the  action  of  microbiall3^-generated  toxins,  operable 
only  in  certain  individuals. 

Eacial  characteristics  modify  liability  to  phagedena,  the  negro  being 
especially  predisposed  to  it,  as,  indeed,  he  is  to  a  severe  type  of  any  variety 
of  venereal  disease  with  which  he  may  be  afflicted.  Why  this  is  so  has  never 
been  satisfactorily  explained.  Possibly  venereal  diseases  are  comparatively 
new  to  the  negro  race,  as  is  true  of  small-pox.  Although  idios3^ncrasy  is  all- 
important  in  the  etiology  of  phagedena,  it  is  by  no  means  the  only  cause. 
In  a  general  way,  it  may  be  said  that  any  disease  or  condition  that  lowers 
tissue-vitality  predisposes  to  it.  Old  age,  malaria,  alcoholism,  the  adynamic 
fevers,  syphilis,  the  cancerous  cachexia,  bad  air,  food,  and  water,  insufficient 
food,  scrofula,  and  scurvy  may  act  as  predisposing  causes.     Hospitalism 


^  Irrespective  of  any  special  poison  in  phagedena,  it  must  be  acknowledged  that 
the  secretion  of  phagedenic  nicer  is  at  least  more  irritating,  on  the  average,  than  that 
from  simple  chancroid.  This  the  author  believes  may  be  verified  by  frequent  experi- 
ments in  autoinoculation. 


DIAGNOSIS    OF    CHANCEOID.  393 

probably  explains  many  cases,  and  also  partly  explains  the  infreqnency  with 
which  we  meet  phagedena  in  private,  as  compared  with  hospital,  practice. 

JSTumerous  local  causes  favor  phagedena,  uncleanliness  being  a  prime 
factor.  Only  by  scrupulous  attention  to  the  genital  toilet  can  such  condi- 
tions be  prevented  in  most  cases  of  chancroid.  Any  irritating  secretion  pre- 
disposes to  phagedena  in  suitable  subjects.  In  women,  especially,  it  is  diffi- 
cult to  keep  the  parts  clean,  and  in  both  sexes  the  urine  is  very  apt  to  come 
in  contact  with  the  ulcer  and — especially  if  it  be  allowed  to  remain  and  de- 
compose— produce  great  irritation.  Phimosis  is  a  prolific  cause  in  the  male, 
through  retention  of  pus  and  other  unhealthy  secretions.  Very  often  self- 
treatment  is  at  the  bottom  of  the  difficulty,  although  the  patient  rarely 
admits  it.  Eicord  asserts  that  mercurial  ointment  is  extremely  irritating 
and  is  often  a  cause  of  phagedena.  Any  rancid  ointment  will  act  in  the 
same  manner  both  by  its  own  irritating  properties  and  the  damming  back 
of  secretions  that  it  produces.  Grease  is  incompatible  with  cleanliness. 
Irritating  powders  often  have  a  similar  effect.  Last,  but  not  least,  we  have 
the  careless  application  of  caustics. 

Simple  Papillomata.  —  Vegetations  constitute  the  mildest  complica- 
tion of  chancroid.  These  papillary  growths  have  already  been  dealt  with  in 
considering  the  simple  external  afi:ections  of  the  sexual  apparatus.  In  chan- 
croid, vegetations  usually  occur  only  after  the  sore  has  shown  a  tendency  to 
become  chronic.  They  merit  no  special  consideration  in  connection  with 
this  disease,  excepting,  perhaps,  that  it  may  be  well  to  caution  against  cut- 
ting them  before  the  chancroid  has  lost  its  specific  properties.  Should  it 
be  done  prior  to  this  time,  autoinoculation  will  probably  occur,  and  create 
much  additional  trouble. 

Syphilis. — Syphilis  as  a  complication  of  chancroid,  either  as  a  primary 
sore  or  a  constitutional  disease,  should  be  borne  in  mind,  as  it  may  mark- 
edly modify  the  characters  of  the  chancroid,  and,  more  than  all,  may  seri- 
ously retard  healing.  This  disease  acts  not  only  specifically,  but  generally; 
few  diseases  so  profoundly  modify  nutrition.  The  possibility  of  the  exist- 
ence of  the  syphilitic  dyscrasia  should  always  be  taken  into  consideration 
when  a  chancroid  becomes  obstinate  and  ceases  to  heal.  The  difference  in 
the  rapidity  of  healing  before  and  after  antisyphilitic  treatment  is  often 
remarkable.  A  brilliant  cure  of  chronic  chancroid  may  occasionall)^  be  ac- 
complished through  a  knowledge  of  this  important  fact. 

Adenitis.  —  The  most  frequent  and  important  complication  of  chan- 
croid is  adenitis,  or  bubo,  which  will  be  considered  later. 

Diagnosis. — The  diagnosis  of  typic  chancroid  requires  its  differentia- 
tion from  chancre,  simple  ulcerated  abrasions,  ulcerating  herpes,  balanitic 
excoriations,  simple  ecthyma,  furuncle,  ulcerating  mucous  patches,  tertiary 
or  gummy  ulceration,  and,  in  very  rare  instances,  from  epithelioma.  There 
is  but  little  liability  to  error  in  diagnosis,  however,  save  in  true  chancre, 
herpetic  ulcers,  ulcerated  abrasions,  and  ecthyma. 


394  CHANCROID. 

The  simple  affections  mentioned  do  not  bear  so  constant  a  relation  to 
sexnal  intercourse  as  chancroid  and  hard  chancre,  and  may  usually  be  diag- 
nosed readily  enough  if  typic  and  seen  early.  They  are  the  result  of 
numerous  influences  independent  of  venereal  and  local  causes.  They  often 
depend  upon  debility  and  certain  nervous  conditions  in  conjunction  with 
various  sources  of  local  irritation,  and  are  an  occasional  result  of  fever.  A 
tight  prepuce,  uncleanliness,  traumatism  during  masturbation,  and  irrita- 
ting discharges  and  applications  may  cause  these  simple  lesions  in  persons 
who  seldom  or  never  have  intercourse.  They  often  bear  a  certain  relation 
to  chancroid,  it  is  true,  and  may  be  the  result  of  irritating  discharges  com- 
ing in  contact  with  the  parts  during  copulation,  but  they  are  in  no  sense 
venereal. 

In  the  case  of  herpes,  ulcers  from  balanitis,  and  ulcerating  excoriations, 
the  secretions  are  neither  heteroinoculable  nor  autoinoculable.  In  ech- 
thyma — impetigo — the  pus  is  not  autoinoculable,  and,  in  addition,  there  is 
usually  a  crop  of  pustules  distributed  more  or  less  extensively  over  the  body. 
Furuncles  may  resemble  chancroid  at  first,  but  they,  are  not  followed  by 
ulceration,  as  a  rule. 

It  must  be  remembered  that  these  simple  lesions  under  favorable  cir- 
cumstances may  be  transformed  into  lesions  that  are  clinically  almost,  if 
not  quite,  identic  Avith  chancroid.  The  secretion  from  any  of  them  when 
autoinoculated  may  j)roduce  a  pustule  or  even  ulceration  from  simple  pus- 
infection. 

The  course  of  these  lesions  as  well  as  their  physical  appearances  gen- 
erally differ  markedly  from  typic  chancroid,  although  some  of  them,  and 
herpes  in  particular,  may  closely  simulate  that  disease.  In  stating  that  the 
simple  affections  above  alluded  to  bear  no  relation  to  sexual  indulgence  the 
author  means  that  they  primarily  bear  no  other  relation  than  is  incidental 
to  friction  and  exposure  to  filth.  In  cases  in  which  the  source  of  irritation 
is  derived  during  sexual  intercourse  the  various  simple  affections  have  no 
definite  period  of  incubation,  either  apparent  or  real.  They  are  apt  to  come 
on  within  a  very  short  time,  but  this  is  variable.  Occasionally  an  examina- 
tion of  the  j)erson  from  whom  the  lesion  is  supposed  to  have  been  contracted 
will  assist  in  the  diagnosis,  but  such  examinations  are  usually  merely  of 
relative  value. 

The  period  of  incubation  in  venereal  sores  may  or  may  not  be  of  value; 
rarely,  indeed,  can  it  be  positively  determined,  as  the  patient  has  usually 
exposed  himself  with  a  number  of  different  females  within  a  comparatively 
short  period  of  time,  and  it  is  well-nigh  impossible  to  determine  in  such 
cases  exactly  when  infection  occurred.  Even  where  the  patient  has  been 
having  intercourse  with  but  one  woman,  it  is  often  impossible  to  decide 
when  the  disease  was  contracted. 

The  chief  difficulty  is  the  differentiation  of  chancre  and  chancroid. 


DIFFEEENTTAL    DIAGXOSIS. 


295 


The  following  table — modified  from  Bumstead — presents  the  chief  points 
in  differential  diagnosis: — 


The  Chancroid. 

Origin  (confrontation). 

Always  due  to  contagion  from  chan- 
croid or  chaucroidic  bubo  or  lym- 
phitis,  either  mediately  or  immedi- 
ately. 

Incuhation. 

None;  the  sore  appears  within  a 
week  after  exposure. 

Commencement. 

Commences  as  a  pustule,  or  as  an 
open  ulcer,  as  a  rule,  but  may  begin 
as  an  abrasion  or  perhaps  a  papule. 

Number. 

Most  often  multiple,  either  from  the 
first  or  by  successive  inoculation. 


Deiyth. 

Perforates  the  whole  thickness  of 
the  skin  or  mucous  membrane; 
"punched  out"  and  excavated,  with 
evident  loss  of  tissue. 

Edges. 

Abrupt,  sharply  cut,  eroded,  under- 
mined. 

Floor. 

Whitish,  grayish,  pultaceous,  "worm- 
eaten." 


Secretion. 

Abundant  and  purulent  unless  com- 
plicated by  inflammation,  and  auto- 
inoculable. 

Induration. 

No  induration  of  the  base  of  the 
lesion,  although  may  be  caused  by 
caustics  or  other  irritant  applications, 
or  even  by  simple  inflammation.  In 
such  event  the  engorgement  is  not  cir- 
cumscribed, but  shades  off  into  the 
surrounding  tissues  and  is  of  short 
duration.     May  be  quite  painful. 

Destructive  Tendency. 

This  is  characteristic  in  typic 
■chancroid  and  very  marked  in  the 
phagedenic  variety.  May  become 
chronic  and  last  for  years. 


The  Chancre. 

Origin  (confrontation). 

Always  due  to  contagion  from  the 
secretion  of  a  chancre,  syphilitic  lesion, 
or  from  the  blood  of  a  person  affected 
with  syphilis,  mediately  or  immedi- 
ately. 

Ificubation. 

Constant  ;  usually  of  from  ten  days 
to  three  weeks'  duration,  often  longer. 

Commencement. 

Commences  as  a  papule  or  tubercle, 
w'hich  afterward,  in  most  cases,  be- 
comes ulcerated.  May  begin  as  a 
small  ulcer. 

Number. 

Generally  single;  multiple,  if  at  all, 
from  the  first,  rarely  if  ever  by  suc- 
cessive inoculation. 

Depth. 

Most  frequently  a  superficial  ero- 
sion "scooped  out,"  fiat,  or  elevated 
above  the  surface;  rarely  deep,  and 
then  cup-shaped,  sloping  toward  the 
center. 

Edges. 
Sloping,  flat,  or  rounded,  adherent. 

Floor. 

Eed,  livid,  or  copper-colored;  often 
iridescent.  Sometimes  covered  by  a 
false  membrane,  scaly  exfoliation,  or 
scabs. 

Secretion. 

Scanty  and  serous,  in  the  absence  of 
complications.  Autoinoculable  with 
great  difficulty,  if  at  all. 

Induration. 

Firm,  cartilaginous,  or  woody  to  the 
feel;  movable  upon  sublying  tissues; 
sometimes  very  thin,  resembling  parch- 
ment beneath  the  skin.  Generally 
persists  for  some  weeks  or  perhaps 
months.  Typically  a  non-inflamma- 
tory neoplasm.  Perfectly  painless  xm.- 
less  inflamed. 

Destructive  Tendency. 

Phagedena  rare,  with  greater  tend- 
ency to  self-limitation.  Should  phage- 
dena occur,  it  rarely  becomes  chronic. 


296 


CHANCROID. 


The  Chancroid   (continued). 

Number  of  Attacks. 

Indefinite.  May  attack  the  same 
subject  any  number  of  times.  Suscep- 
tibility is  never  lost  excepting  after 
numerous  autoinoculations,  such  loss 
being  only  temporary. 

Lymphangitis. 

Acute  inflammation  not  infrequent. 
May  result  in  abscess,  or  even  in  genu- 
ine erysipelas.  May  denude  the  parts, 
or  cause  extensive  burrowing  with  re- 
sulting sinuses. 

Adenitis. 

Ganglionic  reaction  is  present  in 
about  one-third  of  the  cases.  When 
present  it  is  inflammatory  and  sup- 
puration is  frequent;  pus  often  auto- 
inoculable. 

Transmission  to  Animals. 

May  be  transmitted  to  the  lower 
animals. 

Prognosis. 

Always  a  local  affection;  the  gen- 
eral system  never  infected.  May  be- 
come chronic  and  incurable.  May  be 
fatal. 


Effects  of  Treatment. 

Treatment  by  mercury  always  use- 
less and  in  most  cases  injurious. 
(Save  where  complicated  by  syphilis.) 


The  Chancre    (continued). 

Number  of  Attacks. 

Rarely  but  one,  protection  from  a 
second  attack  being  always  partial 
and  generally  complete. 


Lympliangitis. 

Acute  inflammation  and  suppura- 
tion rare.  Chronic  hyperplasia  of  a 
jjainless  character  is  usually  present, 
although  not  always  perceptible  ex- 
ternallJ^  Not  destructive,  and  no 
burrowing  of  pus  Avith  consequent 
sinuses. 

Adenitis. 

Superficial  ganglia  on  one  or  both 
sides  enlarged  and  indurated,  painless, 
freely  movable;  suppuration  rare  and 
pus  not  autoinoculable. . 

Transmission  to  Animals. 

Peculiar  to  the  human  race.  But 
may  possibly  be  transmitted  to  ani- 
mals. 

Prognosis. 

A  constitutional  disease;  general 
symptoms  usually  occur  in  about  six 
to  eight  weeks  after  the  appearance  of 
the  sore,  very  rarely  later  than  three 
months.     Never  fatal  per  se. 

Effects  of  Treatment. 

Improves  under  the  influence  of 
mercury. 


An  "ulcerating  niucons  patch  may  be  mistaken  for  chancroid.  This 
lesion,  when  sitnated  about  the  genitals,  is  so  subjected  to  heat,  moisture, 
and  local  irritation  that  it  sometimes  becomes  transformed  into  an  ulcer 
closely  simulating  chancroid.  It  usually  co-exists  with  patches  in  the  mouth 
or  about  the  anus,  and  is  apt  to  be  associated  with  either  general  syphilides 
or  condylomata  or  both.  It  is  rarely  ulcerated  so  deeply  as  chancroid,  and 
its  secretion  is  not  only  scanty  and  serous,  as  a  rule,  but  is  not  autoinocu- 
lable. It  is  not  subject  to  phagedena,  and  shows  no  tendency  to  extensive 
tissue-destruction.  It  is  also  unaccomj)anied  by  marked  adenitis,  as  a  rule, 
and  never  leads  to  the  virulent  form.  If  adenitis  occurs  it  is  the  result  of 
mixed  infection. 

Tertiary  or  syphilomatous  ulcer  of  the  genitals  sometimes  closely  re- 
sembles chancroid.  The  differential  diagnosis  can  only  be  made  by  careful 
study  of  the  history,  physical  characters,  and  inoculability  of  the  lesion. 
The  preliminary  syphilomatous  neoplasm  of  the  syphilitic  lesion  is  the  im- 
portant feature  in  the  physical  history  of  the  case.    If  the  patient  be  trust- 


DIFFERENTIAL    DIAGNOSIS.  397 

worthy,  a  history  of  prolonged  continence  may  clear  up  the  diagnosis. 
There  is  more  induration  in  the  syphilitic  lesion  than  in  chancroid,  and 
this  enlargement  is  always  painless  unless  inflammation  sets  in.  Bubo  is 
usually  absent  or  slight  in  the  sequelar  syphilitic  ulcer,  unless  some  super- 
added source  of  infection  exists. 

Whenever  it  is  found  necessary  to  perform  autoinoculation  in  order  to 
clear  up  certain  diagnostic  points,  some  spot  should  be  selected  for  the 
operation  in  which  there  are  no  immediately  contiguous  lymphatic  glands. 
AVhere  convenient,  the  skin  of  the  chest  beneath  the  nipple  may  be  selected. 
The  inner  aspect  of  the  thigh  is  not  so  safe,  perhaps,  on  account  of  the 
proximity  of  the  femoral  glands,  but  it  is  usually  more  accessible.  In  sub- 
preputial  or  urethral  chancroid  the  diagnosis  can  only  be  made  by  auto- 
inoculation, although  a  painful  spot  in  the  urethra  followed  by  suppurating 
bubo  is  very  signiiicant. 

As  soon  as  a  characteristic  result  has  been  produced,  if  such  occur,  the 
site  of  inoculation  should  be  thoroughl}^  cauterized. 

Autoinoculation  rarely,  if  ever,  fails  in  typic  chancroid,  unless  phage- 
dena or  gangrene  has  destroyed  the  virulent  properties  of  its  secretion. 
Under  such  circumstances  an  erroneous  opinion  may  be  formed  on  account 
of  the  negative  result  of  autoinoculation,  the  sore  being  pronounced  syph- 
ilitic and  constitutional  syphilis  prognosticated.  Again,  mixed  sores  afford 
a  prolifie  source  of  diagnostic  confusion,  as  they  are  autoinoculable  and  the 
surgeon  may  decide  in  favor  of  chancroid  and  against  the  possibility  of  con- 
stitutional syphilis.^ 

After  all  that  has  been  said  regarding  the  differential  diagnosis  of  chan- 
cre, chancroid,  and  simple  lesions  of  the  g&nitals,  it  must  he  acknowledged 
that  it  is  never  safe  to  pronounce  against  the  possibility  of  syphilis  in  any 
indurated  or  ulcerative  lesion  upon  the  genitals.  Many  a  trifling  and  ap- 
parently simple  sore,  wnd  many  apparently  typic  chancroids  of  both  severe 
and  mild  types,  are  followed  by  syphilis.  Such  atypic  cases  are  the  chief 
argument  of  the  unicists,  and  demand  extreme  diagnostic  and  prognostic 
caution.  As  a  matter  of  routine,  the  practitioner  is  only  safe  in  stating  the 
possibility  of  syphilis  in  all  genital  sores,  however  be-nign  they  may  appear. 
The  value  of  differential  diagnostic  tables  is  therefore  open  to  question. 

Diagnosis  of  Chronic  Chancroid. — The  only  lesions  for  which  chronic, 
chancroid  can  j)ossibly  be  mistaken  are  the  tubercular  syphilide  of  the 
sequelar  period  and  epithelioma.     If  the  patient  be  known  to  have  syph- 
ilis, there  may  be  great  difficulty  of  differentiation.    The  history  of  the  case 
is,  of  course,  very  useful  in  diagnosis.    In  syphilis  the  syphilomatous  deposit 

^  Campana  has  called  attention  to  the  fact  that  if  some  hard  ulcers  be  irritated, 
the  secretion  becomes  capable  of  producing  an  apparently  typic  soft  sore  by  auto- 
inoculation. He  believes,  moreover,  that  the  soft  sore  is  an  aflfection  belonging  to 
general  rather  than  special  surgery.  Giornale  Italiano  del  Mai.  e  Veneree  del.  Pelle, 
March,  1883. 


298  CHAXCEOID. 

occurs  primarily,  and  ulceration  secondarily,  while  in  chancroid  the  ulcer 
is  jDrimary  and  the  hardening  and  thickening  of  tissue  secondary.  Small 
portions  of  the  characteristic  deposit  often  remain  about  the  gummy  syph- 
ilitic ulcer,  and  effectually  settle  the  diagnosis.  If  not  too  late  in  the  case 
autoinoculation  is  a  crucial  test  for  chancroid.  Finally,  the  best  of  all  is  a 
course  of  mercury  and  iodin,  for  if  the  condition  be  syphilitic  it  will  almost 
inevitably  clear  up,  while,  if  it  be  chancroid,  it  will  not  only  fail  to  5deld  to 
treatment,  but  may  grow  worse  under  it.  Cancer  may  often  be  excluded 
by  the  history,  but  the  case  may  be  sufficiently  confusing  to  require  micro- 
scopic investigation. 

Peogxosis. — The  prognosis  in  chancroid  is  generally  good.  When  bad 
or  doubtful,  it  is  dependent,  not  upon  the  chancroid  per  se,  but  upon  various 
serious  complications.  Even  in  extensive  phagedena  recovery  is  usual,  the 
danger  being  loss  of  tissue  rather  than  death  of  the  individual.  An  excep- 
tion must  be  made  in  the  case  of  the  extensive  chronic  chancroids  already 
described.  These  lesions  sometimes  prove  fatal,  but  even  in  such  cases  the 
fatal  result  is  usually  due  to  some  intercurrent  affection  superinduced  by 
exhaustion.  Man}^  cases  of  chancroid  might  possibly  prove  fatal  were  their 
complications  allowed  to  progress  unchecked;  the  fatal  cases  are  those  in 
which  phagedena,  gangrene,  or  erysipelas  have  either  been  neglected  or  have 
not  yielded  to  treatment.  In  a  few  such  instances  the  patient  dies  from  the 
combined  effects  of  exhaustion,  septemia,  and  pain. 

The  destruction  of  tissue  that  chancroid  is  capable  of  producing  is  most 
to  be  dreaded.  The  organs  of  generation,  especially  in  the  male,  may  be  so 
far  destroyed  as  to  practically  unsex  the  individual.  A  case  of  this  kind 
occurred  in  the  author's  hospital  service: — ■ 

Case. — An  Italian,  about  30  years  of  age,  had  contracted  chancroid  some  weeks 
prior  to  his  admission  to  the  hospital,  and  had  sadly  neglected  it.  By  the  time  he  con- 
cluded to  seek  advice  the  process  had  become  gangrenous,  or  possibly  phagedenic,  and 
when  he  finally  came  to  the  hospital  for  repairs  his  penis  had  been  completely 
amputated  at  its  root.  The  final  appearance  of  this  case  was  very  peculiar.  The  in- 
tegument had  closed  in  about  the  root  of  the  organ,  and  a  valve-like  fold  of  skin  so 
completely  hid  the  urethra  from  sight,  that  it  could  only  be  seen  by  lifting  the  flap. 
Thus  the  surface  of  the  pubes  was  almost  perfectly  smooth,  without  even  the  slightest 
elevation  to  mark  the  spot  formerly  occupied  by  the  penis. 

A  precisely  similar  case  of  serious  destruction  of  tissue  by  chancroid  is 
reported  by  Eemondino.  The  severity  of  this  case — that  of  a  native  Mex- 
ican— was  also  due  to  neglect.^ 

The  cicatrices  resulting  from  severe  chancroids  are  sometimes  very  ex- 
tensive and  productive  of  great  deformity.  The  degree  of  damage  depends, 
in  a  measure,  upon  the  situation  of  the  scar.  Chancroids  of  the  meatus  and 
urethra  are  inevitably  followed  by  stricture  of  severe  type. 


^  Journal  of  Cutaneous  and  Venereal  Diseases,  vol.  i.  No.  2. 


TEEATMENT    OF    CHANCEOID.  299 

Teeatment  of  Chanceoid. — Prophylaxis. — The  prophylaxis  of  chan- 
croid involves  that  of  gonorrhea,  and,  in  a  measure  at  least,  also  that  of 
sj'philis. 

Consistently  with  the  evolutionary  theory  of  the  origin  of  chancroid 
and  gonorrhea,  prophylaxis  must  begin  with  the  hot-bed  of  cultivation  it- 
self: i.e.,  with  the  vagina  of  the  female.  It  is  in  this  laboratory  of  organic 
poisons  that  the  infections  of  these  diseases  are  elaborated,  and,  obviously, 
attention  should  first  be  given  to  the  favoring  circumstances  known  to  exist 
in  many  women.  Prostitutes,  professional  or  clandestine,  should  be  under 
surveillance.  It  is  true  that  the  method  in  vogue  in  Paris  is  very  faulty, 
and  apt  to  work  great  injury  in  special  cases,  and  the  author  is  far  from 
advocating  an  identic  surveillance  in  our  own  social  system,  but  much 
good  might  be  done  by  a  modification  of  it.  The  Parisian  method  for  the 
regulation  of  the  social  evil,  with  all  its  faults,  has  proved  to  be  productive 
of  much  benefit.  Eespecting  chancroid,  Mauriac  has  shown  that  the  dis- 
ease has  decreased  considerably  under  the  modern  system  of  police-regula- 
tion. The  registration  of  prostitutes,  and  the  licensing  of  bagnios  may  not 
be  pleasant  to  the  mind  of  the  theoretic  moralist,  but  in  the  light  of  pre- 
ventive medicine  it  has  its  manifest  advantages.  Laws  might  be  enacted 
compelling  the  proprietors  of  licensed  houses  to  submit  their  inmates  to 
frequent  and  thorough  medical  inspection.  Women  who  are  suffering  with 
known  infection,  or  with  severe  forms  of  utero-vaginal  infiammation,  should 
be  quarantined  until  recovery,  or  at  least  until  the  infection  has  disappeared, 
on  the  one  hand,  or  great  improvement  is  evident,  on  the  other.  The  poor 
unfortunates  of  the  lower  grade  of  prostitutes  should  be  confined  in  public 
institutions  established  for  the  purpose  until  they  cease  to  be  dangerous 
to  the  health  of  the  community.  Prostitution  is  coeval  with  society,  and 
probably  will  always  exist;  hence,  the  sooner  we  cease  moralizing  and  deal 
with  the  subject  from  a  philosophic  stand-point,  the  better  it  will  be  for 
civilization.  Prostitution  cannot  be  prevented,  nor  is  it  certain  that  it 
would  be  wise  to  suppress  it,  but  it  can,  and  sooner  or  later  must  be,  regu- 
lated. 

This  much  is  certain,  viz.:  that  supervision  of  the  health  and  habits 
of  prostitutes  would  lessen  the  frequency  of  venereal  disease  in  great  meas- 
ure, cleanliness  being  by  far  the  most  important  factor  in  this  result. 

The  male  sex  should  come  in  for  its  share  of  responsibility  for  venereal 
contagion.  It  may  not  be  possible  for  the  profession  to  teach  all  men  that 
even  immorality  may  be  mitigated  by  cleanliness,  but  every  physician  can 
contribute  his  mite  of  infiuence  for  the  public  weal.  Why  it  should  be 
necessary  to  impress  upon  the  minds  of  some  men  that  they  ought  to  ab- 
stain from  sexual  congress  while  affected  by  venereal  disease  is  difficult  of 
conjecture,  but  certain  it  is  that  many  men  have  so  little  decency  that  they 
will  indulge  their  licentiousness  while  still  suffering  from  a  urethral  dis- 
charge, a  more  or  less  plainly-marked  hard  or  soft  chancre,  or  a  mucous 


300  CHAXCKOID. 

jDatch  upon  the  genitals.  To  be  fair  to  both  sides,  prostitutes  should  be 
advised  to  demand  that  each  of  their  patrons  submit  to  a  preliminary  in- 
spection. 

Such  measures  as  those  outlined  would,  if  they  could  be  effectually 
carried  out,  not  only  diminish  the  frequency  of  chancroid  and  gonorrhea  to 
a  great  extent,  but  would  also  decrease  the  number  of  syphilitics,  hereditary 
as  well  as  acquired. 

In  suggesting  measures  of  prophylaxis  it  is,  of  course,  taken  for  granted 
that  absolute  safety  lies  only  in  the  strictest  virtue.  But  as  physicians  we 
are  compelled  to  face  the  conditions  as  they  exist,  and  always  will  exist, 
unless  human  nature  changes. 

After  exposure  in  suspicious  intercourse  much  may  be  done  by  both 
male  and  female  to  prevent  contagion.  In  women  vaginal  injections  of  a 
solution  of  mercuric  chlorid,  chloral-hydrate,  carbolic  acid,  tincture  of  iodin, 
or  potassium  permanganate  will  effectually  prevent  infection,  unless  chan- 
croidic  or  syphilitic  poison  has  been  already  absorbed  through  some  breach 
of  surface  in  the  skin  or  mucous  membrane. 

In  the  male,  careful  washing  with  soap  and  water,  followed  by  any  of 
the  solutions  above  mentioned,  will  prove  effectual  unless,  as  is  stated  in 
the  case  of  the  female,  absorption  has  already  occurred,  in  which  case  they 
are  valueless.  Prompt  urination  followed  by  solution  of  mercuric  chlorid, 
will  prevent  gonorrhea,  as  a  rule.  Silver-nitrate  solution  is  also  efficacious. 
Any  of  these  applications  require  the  advice  of  the  physician,  in  order  that 
they  may  be  used  intelligently,  and  in  proper  strength,  otherwise  serious 
trouble  may  result. 

Whenever,  after  suspicious  intercourse,  slight  abrasions  are  noticed,  the 
parts  should  be  thoroughly  washed  with  some  antiseptic  solution — prefer- 
ably p3^rozone,  3  per  cent. — and,  after  thorough  dr3dng,  each  denuded  spot 
should  be  thoroughly  cauterized  with  fuming  nitric  acid.  Silver  nitrate  is 
quite  generally  used,  but  is  the  worst  thing  possible  for  infected  wounds. 
It  produces  more  irritation  in  the  end  than  mineral  acids  or  the  thermo- 
cautery, and,  being  but  a  superficial  caustic,  it  merely  coagulates  the  albu- 
min upon  the  surface  of  the  lesion,  thus  sealing  up  the  infection  in  the  tis- 
sues to  perform  its  work  of  destruction  Avithout  opposition  and  more  vi- 
ciously than  if  nothing  had  been  done.  Inflamed  tissues  are  favorable  soil 
for  the  development  of  infection.  These  remarks  apj^ly  also  to  the  treat- 
ment of  the  bites  of  animals,  dissecting  wounds,  and  infected  lesions  of  all 
kinds.  The  student  on  entering  the  dissecting-room  should  abjure  the 
time-honored  stick  of  caustic  if  he  would  not  enhance  the  dangers  of  dis- 
section. 

In  presenting  these  various  measures  of  prophylaxis  the  author  does 
not  wish  to  be  understood  as  tacitly  sanctioning  fornication.  What  has 
been  said  has  been  directed  to  the  mitigation  of  the  results  of  what  seems 
at  present  to  be  an  unavoidable  evil. 


TKEATMENT    OF    CHANCEOID.  301 

Surgical  Treatment. — When  a  commencing  or  fully-developed  chan- 
croid is  presented  for  treatment,  Nature  should  be  imitated  so  far  as  pos- 
sible by  converting  the  so-called  specific  sore  into  a  simple  ulcer.  This 
indication  demands  thorough  cauterization.  The  thermocautery  or  gal- 
vanocautery  is  the  best  method. 

An  8-per-cent.  solution  of  cocain  muriate  or  eucain  applied  five  minutes 
prior  to  cauterization  will  make  the  operation  absolutely  painless.  If  the 
cold  button  or  wire  loop  of  the  galvanoeautery  be  applied  first,  and  heated 
while  in  contact  with  the  anesthetized  area,  the  patient's  nervous  appre- 
hension will  be  avoided.  A  pinch  of  the  dry  alkaloid  laid  upon  the  surface 
of  the  ulcer  is,  perhaps,  more  active  than  the  solution  of  cocain.  In  lieu 
of  cocain  or  eucain  there  is  nothing  so  effectual  as  pure  carbolic  acid,  a  drop 
of  which  will  markedly  mitigate  the  pain  of  subsequent  cauterization. 

In  the  absence  of  the  galvanoeautery  the  best  application  is  fuming 
nitric  acid.  The  surface  must  first  be  thoroughly  dried  with  absorbent 
cotton  or  blotting-paper,  after  which  the  acid  is  applied  by  means  of  a 
small  glass  rod,  or  a  cotton-wrapped  wooden  point.  After  the  caustic  has 
done  its  work  thoroughly,  a  pinch  of  sodium  bicarbonate  should  be  applied 
to  neutralize  any  excess  of  acid.  Every  portion  of  the  affected  surface  and 
every  suspicious  spot  must  be  completely  destroyed,  else  reinfection  will 
occur  as  soon  as  the  sloughs  produced  by  the  cauterant  separate  and  expose 
the  sublying  raw  surfaces. 

The  form  of  caustic  is  by  no  means  a  matter  of  indifference.  The  solid 
stick  of  silver  nitrate  is  often  used,  and  not  infrequently  produces  severe 
inflammation.  Gangrenous  sloughing  and  phagedena  are  among  the  possi- 
bilities. Yet  nitrate  of  silver  has  its  advocates,  who  probably  attribute  their 
unfavorable  results  to  Providence  and  the  natural  course  of  the  disease. 
The  average  patient  whom  unlucky  circumstances  have  provided  with  a 
stick  of  silver  nitrate  is  like  a  bull  in  a  china-shop,  and  does  about  as  much 
damage.  Silver  nitrate  has  its  uses  in  chancroid,  but  it  should  never  be 
used  until  all  destructive  properties  have  been  corrected  and  the  sore  is 
in  process  of  repair  as  a  simple  ulcer.  Then,  and  then  only,  it  is  useful  to 
stimulate  repair,  allay  irritability,  or  repress  exuberant  granulations,  as 
the  case  may  be. 

Pure  bromin  is  a  most  reliable  caustic,  but  unstable  and  too  inconven- 
ient for  routine  use. 

Several  other  caustics  are  useful  after  the  surgeon  has  familiarized 
himself  with  their  properties  and  uses.  The  familiar  mixture  of  the  chlorid 
of  zinc  and  flour,  known  as  "Canquoin's  paste,"  and  much  used  by  both 
respectable  surgeons  and  quacks  in  the  treatment  of  neoplasms,  is  an  ex- 
cellent caustic.  Potassic  hydrate  with  lime  and  the  Vienna  paste — a  com- 
bination of  charcoal  and  sulphuric  acid — are  also  useful  as  destructive  cau- 
terants.  Eicord  highly  recommends  the  carbo-sulphuric  paste,  it  being  ap- 
parently his  favorite  caustic. 


303  CHANCROID. 

Where  chancroid  is  inflamed  or  very  large  and  multiple,  and  when  the 
prepuce  is  tight  the  patient  should  be  put  to  bed  after  cauterization  until 
the  sloughs  separate,  which  will  be  within  three  or  four  days.  The  patient 
should  always  be  apprised  of  the  necessity  of  keeping  the  parts  perfectly 
clean. 

Moist  antiseptic  dressings  are  usually  advisable  after  cauterization,  if 
the  latter  is  extensive.  A  piece  of  lint  or  soft  gauze  should  be  wrapped 
about  the  part,  and  kept  constantly  wet  with  a  solution  of  the  mercuric 
chlorid  1  to  5000.  This  is  cleanly  and  antiseptic,  and  tends  to  prevent  in- 
flammatory complications.  Any  mild  antiseptic  lotion  will,  however,  an- 
swer the  same  purpose.    Boric-acid  solution  is  one  of  the  best. 

After  the  sloughs  have  separated,  a  dry  dressing  may  be  used,  although 
the  water-dressing  is  still  preferable  in  many  cases.  The  best  dry  applica- 
tion is,  without  question,  the  old  stand-by,  iodoform.  This  may  be  applied 
in  any  form,  providing  its  chemic  composition  be  not  altered.  An  excellent 
method  is  by  means  of  an  ethereal  solution: — 

IJ  lodoformi    3ij. 

Jiltlier.  sulph §j. 

M.     Sig. :   Apply  with  a  camel's-hair  pencil  several  times  daily. 

By  means  of  this  solution  a  thin  film  of  the  drug  is  deposited  upon  the 
surface  of  the  ulcer. 

Another  useful  formula  is  the  following: — 

IJ  lodoformi 3ij. 

Tr.  benzoini  co Sj. 

M.     Sig.:    Apply  with  a  swab  of  cotton. 

The  chief  advantage  of  this  method  of  using  iodoform  is  that  a  water 
dressing  may  be  applied  over  it. 

Glycerin  and  alcohol  form  a  good  vehicle  for  the  application  of  iodo- 
form.   As  recommended  by  Ashurst,  the  formula  is  as  follows: — 

I^  lodoformi    3ss., 

Glycerini   3ij. 

Sp.  vini  reet 3ij. 

M.     Sig.:    Apply. 

Dry  iodoform  powder  is  to  be  preferred  as  a  matter  of  routine.  It 
should  be  finely  triturated,  and  when  applied  pressed  down  so  as  to  enter 
all  of  the  little  irregularities  in  the  surface  of  the  ulcer.  A  small  bit  of 
oiled  silk  or  water-proof  paper  laid  over  the  ulcer  will  prevent  the  external 
dressings  from  adhering  to  the  diseased  surface.  Absorbent  cotton  laid 
over  this  will  take  up  the  secretions  that  freely  escape  from  under  the  pro- 
tective dressing.  In  conjunction  with  the  iodoform  the  ulcer  should  be 
cleansed  several  times  daily  with  pyrozone. 

When  repair  begins,  iodoform  with  balsam  of  Peru  is  an  excellent 
stimulant.    This  is  the  only  ointment  that  should  ever  be  used  in  chancroid. 


TEEATMENT    OF    CHANCEOID.  303 

Ordinary  ointments  are  foul  and  dirty  applications  that  speedily  become 
rancid^  producing  the  most  intense  irritation.^ 

The  ointment  of  which  an  exception  has  been  made  is  composed  as 
follows: — 

ij  lodoformi    3ij. 

Bals.  Peru 3iv. 

Lanolini 3iv. 

M.     Sig. :    Apply  on  lint. 

The  greatest  objection  to  iodoform  is^  of  course,  its  offensive  odor. 
Many  patients  refuse  to  use  it  on  this  account.  Its  odor  may  be  disguised 
to  a  great  extent.  Balsam  of  Peru  is  tolerably  effective.  Tannin  has  been 
recommended,  but  it  is  too  bulky  and  irritating.  A  good  formula  is  the 
following : — 

IJ  lodoformi 3iv. 

Nitrobenzolis    m.  v. 

M.     Trit.  subtil. 
Sig.:    Apply. 

The  essential  oils,  such  as  rose  and  verbena,  are  useful,  but  not  so 
effectual  as  nitrobenzol.  Many  attempts  have  been  made  to  deodorize  iodo- 
form, but  without  success.  Iodoform  without  its  characteristic  odor  is 
"Hamlet  without  Hamlet."  lodol  is  a  popular  ''substitute"  that  does  not 
substitute,  but  is  often  useful.  Europhen  and  nosophen  are  also  useful  to  a 
limited  extent. 

Salicylic  acid  has  been  recommended  as  a  substitute  for  iodoform  in 
chancroid  and  bubo,-  and,  while  it  does  not  seem  so  effective  as  that  drug,  it 
sometimes  acts  well  both  alone  and  in  combination  with  bismuth,  oleate  of 
zinc,  or  boric  acid.    A  good  combination  is  the  following: — 

IJ  Ac.  salicyl 3j. 

Bismuthi  subnit •  •  3ij . 

Zinci  oleat 3j. 

M.    Trit.  subtil. 
Sig.:    Apply. 

Salicylic  acid  is  sometimes  too  irritating  and  painful.  This  may  be 
obviated  by  mixing  it  with  a  little  acetate  of  morphia,  cocain,  or  eucain. 
These  latter  drugs  are  always  useful  in  painful  chancroid.  A  new  anes- 
thetic antiseptic  powder  called  orthoform  is  useful  in  painful  sores. 

Andrieu  and  Vidal  highly  indorse  pyrogallic  acid  as  a  substitute  for 
iodoform.^    This  drug  may  be  used  either  as  a  dry  powder,  alone  or  in  com- 


^  Sigmund,  of  Vienna,  uses  mercurial  ointment  as  an  application  to  chancroids. 
Ricord,  Ziessl,  Bumstead,  and  Taylor  all  condemn  its  use,  and  with  reason,  as  it  is 
the  filthiest  of  all  ointments. 

=  Antier,  These  de  Paris,  1881. 

^Andrieu,  "These  de  Paris,"  1881;    Journal  de  Medecine  et  de  Chirurgie. 


304  CHAK-CEOID. 

bination,  or  as  an  ointment.    The  author  has  nsed  it  in  both  ways,  bnt  can- 
not indorse  it. 

Absorbent  powders  of  various  kinds  have  been  used  extensively:  car- 
bonate and  subnitrate  of  bismuth,  oxid  of  zinc,  lycopodium,  and  talcum 
are  among  the  substances  employed.  These  powders  have  the  same  objec- 
tionable features  as  tannin;  they  tend  to  cake  upon  the  part  and  cause  irri- 
tation. Powdered  oleate  and  stearate  of  zinc  are  not  so  objectionable. 
There  are  few  good  preparations  of  this  drug,  most  of  them  being  inclined 
to  beconae  lumpy  and  gritty  after  trituration.  The  powdered  oleate  pre- 
pared by  Parke,  Davis  &  Co.  is  free  from  these  objectionable  features. 
Zinc  should  only  be  used  during  the  process  of  repair. 

As  chancroid  progresses  toward  recovery,  healing  may  at  any  time  be 
retarded  by  either  local  or  constitutional  causes,  necessitating  a  change  of 
treatment.  Lotions  of  silver  nitrate,  zinc  sulphate  and  copper  sulphate,  or 
similar  astringents  are  often  sufficient  to  stimulate  granulation.  An  excel- 
lent vegetable  preparation  is  the  fluid  extract  of  hamamelis,  or  witch-hazel, 
applied  in  full  strength.  The  iodoform  ointment  is  often  successful  in  pro- 
moting healing.  Should  these  milder  measures  prove  insufficient,  or  if 
exuberant  granulations  exist,  the  pure  crayon  of  silver  nitrate  or  copper 
sul^jhate  is  indicated.  Chancroid  sometimes  becomes  very  irritable  and 
painful  during  healing.  Cauterization,  preferably  with  the  galvanocautery, 
will  relieve  this  condition.  When  the  edges  of  the  ulcer  are  much  under- 
mined, they  usually  become  thickened  and  calloused,  seriously  retarding 
healing.  Under  such  circumstances  they  should  be  trimmed  with  scissors. 
The  tissues  surrounding  chancroid  often  become  infiltrated  and  hard- 
ened, thus  impeding  repair;  this  is  especially  liable  to  occur  if  the  prepuce 
be  involved.  This  condition  is  remediable  by  Judicious  strapping  with  ad- 
hesive (diachylon)  plaster. 

Snbpreputial  chancroids  require  careful  syringing  with  antiseptic  solu- 
tions, the  best  of  which  is  pyrozone,  3  per  cent.;  mercuric  chlorid,  1  to  1000, 
is  also  good.  A  flat-nozzled  syringe  has  been  devised  for  eases  of  this  kind, 
but  the  ordinary  syringe  suffices.  The  composition  of  the  lotion  is  not  so 
important,  for  one  antiseptic  is  often  about  as  good  as  another.  Solutions 
of  carbolic,  boric,  and  salicylic  acids;  iodin,  and  potassium  permanganate 
are  all  useful.  The  chief  indication  is  to  inject  the  lotion  frequently.  The 
lotion  should  be  mild,  else  inflammation,  and  perhaps  a  new  crop  of  chan- 
croids, may  be  excited  by  excoriating  the  mucous  membrane  and  thus  af- 
fording new  atria  for  infection.  Where  urination  is  painful,  relief  may  be 
afforded  by  prolonged  soaking  of  the  organ  in  very  hot  water.  If  the  urine 
is  passed  while  the  penis  is  in  the  hot  bath,  pain  will  be  trifling.  Iodoform 
may  be  used  in  snbpreputial  chancroids  by  injecting  a  mixture  of  the  finely 
powdered  drug  in  glycerin,  oij  to  the  ounce.  This  should  be  used  once 
daily  after  a  thorough  washing  with  warm  water,  preferably  at  night.  As 
soon  as  the  prepuce  can  be  retracted,  the  case  is  to  be  managed  as  in  ordi- 


TEEATMENT    OP    CHANCEOID.  305 

nary  cases  of  cliancroid.  Incision  may  become  necessary  in  order  to  expose 
tlie  glans. 

Chancroids  of  the  meatus  should  be  cauterized  with  great  circum- 
spection, if  at  all,  as  any  loss  of  tissue  will  enhance  the  almost  inevitable 
subsequent  stricture.  Especial  care  should  be  taken  to  avoid  ezcess  of  acid. 
The  meatus  may  be  dressed  with  a  small  conic  plug  of  lint  dipped  in  vase- 
lin  and  sprinkled  with  iodoform.  This  should  be  frequently  changed,  and 
will  lessen  cicatricial  contraction.  The  iodoform  and  balsam  ointment  acts 
well  in  these  cases.  After  the  specific  properties  of  the  sore  have  been  de- 
stroyed healing  is  often  slow  on  account  of  the  necessity  of  movement  of 
the  part  and  contact  of  urine.  Under  these  circumstances  the  mixture  of 
iodoform  and  benzoin  affords  a  protective  antiseptic  coating  for  the  ulcer. 
During  cicatrization  the  passage  of  sounds  may  be  necessary  to  prevent  con- 
traction so  far  as  possible;  after  complete  cicatrization  meatotomy  is  often 
required. 

When  chancroid  is  located  within  the  meatus  the  treatment  should  be 
mainly  expectant.  Cauterization  is  difficult  and  rarely-wise.  Fortunately 
such  lesions  are  infrequent  and  generally  mild.  As  in  all  urethral  lesions 
of  whatever  kind,  the  urine  should  be  neutralized,  and  suitable  hygienic 
measures  advised.  Cleanliness  is  promoted  by  urination,  the  consequent 
benefit  being  increased  by  the  free  secretion  of  antiseptic,  or  at  least  un- 
irritating,  urine.  The  internal  administration  of  eucalyptus,  salol,  and 
guaiacol  is  rational  therapy.  Antiseptic  injections  are  of  service,  and  any 
of  the  formulas  recommended  for  subpreputial  chancroids  may  be  used, 
iodoform  and  glycerin  being  especially  valuable.  The  urethra  may  be 
cleansed  with  3-per-cent.  pyrozone  prior  to  injection.  Iodoform  may  be 
applied  very  readily  to  any  part  of  the  urethra  by  means  of  the  endoscope. 
Urethral  suppositories  of  cocoa-butter  are  excellent  vehicles  for  iodoform. 
During  the  healing  of  intra-urethral  ulcers  dilation  must  be  frequently 
practiced,  else  serious  organic  stricture  will  result.  Stricture  is  to  be  ex- 
pected, but  may  be  moderated  by  judicious  sounding.  When  chancroid  is 
situated  beneath  the  frenum  freputii,  the  latter  should  be  cut  through  to 
prevent  rupture  and  troublesome  hemorrhage  from  the  frenal  artery. 

When  severe  inflammation  attacks  chancroid,  the  patient  must  be  put 
to  bed  at  once.  If  the  prepuce  is  long  and  phimosed  and  inflammatory 
swelling  marked,  or  the  discharge  foul  and  fetid,  justifying  a  suspicion  of 
phagedena,  the  lesion  should  be  promptly  exposed  by  dorsal  incision  of  the 
prepuce.  This  incision  should  be  free  enough  to  thoroughly  expose  the 
glans.  The  author  performs  this  operation  in  all  concealed  lesions,  where 
destruction  of  tissue  is  feared,  whether  severe  inflammation  exists  or  not. 

This  plan  has  been  censured  on  account  of  the  danger  of  autoinocula- 
tion  of  the  cut  surfaces,  but  this  is  of  minor  importance  as  compared  with 
the  destruction  of  tissue  occurring  in  some  cases  of  concealed  chancroid, 
and  is  rarely  serious. 


306  CHAXCEOID. 

The  cavity  beneath  the  prepuce  and  about  the  glans  should  first  be 
thoroughly  washed  with  pyrozone  to  remove  tenacious  secretions;  this 
should  be  followed  by  a  solution  of  mercury  bichlorid  1  to  1000.  The  pre- 
puce should  be  divided  upon  the  dorsum  by  means  of  a  straight  director 
and  a  sickle-shaped  bistoury,  or  scissors.  In  nervous  j)atients  cocain  may 
be  used  hypodermically  in  the  line  of  incision.  As  soon  as  the  parts  are 
exposed,  they  should  be  freely  bathed  in  the  bichlorid  solution  and  dried 
with  gauze.  First  the  sores  and  then  the  wound  should  be  thoroughly  cau- 
terized with  carbolic,  followed  by  nitric,  acid.  After  cauterization  the  parts 
should  be  thickly  sprinkled  with  iodoform  and  dressed  with  gauze.  Wet 
dressings  may  be  applied  if  preferred,  and,  if  necessary,  a  bladder  of  ice 
may  be  laid  upon  the  part  to  subdue  inflammation.  Hot  charcoal  and  lin- 
seedmeal  poultices  sprinkled  with  laudanum  sometimes  act  better. 

The  progress  of  such  cases  after  operation  is  generally  favorable,  the 
ulcers  and  line  of  incision  healing  promptly.  Should  healing  be  retarded 
from  any  cause,  the  various  methods  of  stimulation  already  presented  may 
be  used.  Judicious  strapping  is  often  beneficial  in  these  cases.  Should  the 
patient  be  debilitated,  tonics  are  indicated. 

In  cases  in  which  gangrene  or  phagedena  have  begun,  whether  phimosis 
exists  or  not,  there  is  great  danger  of  serious  loss  of  tissue;  hence  treatment 
should  be  both  prompt  and  energetic.  Phimosis  should  be  relieved  by  in- 
cision, sloughs  detached,  the  parts  washed  thoroughly  with  bichlorid  solu- 
tion, and  all  of  the  surfaces  thoroughly  cauterized  either  with  the  actual 
cautery  or  pure  bromin.^  The  latter  is,  in  the  author's  judgi^ient,  by  far 
the  best  caustic  in  these  conditions.  The  work  must  be  done  thoroughly, 
else  the  destructive  jDrocess  will  not  be  checked. 

After  the  operation  the  old-fashioned  charcoal  poultice,  preferably 
mixed  with  brewers'  yeast,  should  be  used  continuously  until  the  sloughs 
separate,  after  which  time  the  treatment  is  that  of  simple  ulcer.  The  poul- 
tice may  be  dusted  with  iodoform,  or,  if  great  pain  be  complained  of,  it 
may  be  sprinkled  with  laudanum.  Sheet  lint  or  gauze  saturated  with  some 
hot  antiseptic  solution  may  be  used  instead  of  the  poultice.  Eicord  recom- 
mends a  solution  of  the  potassio-tartrate  of  iron  in  a  strength  of  20  grains 
to  the  oimce  of  water.  Should  a  single  cauterization  be  insufficient  to  check 
the  disease,  it  must  be  repeated  as  often  as  necessary. 

The  constitutional  treatment  of  phagedena  and  gangrene  is  of  vital 
importance.  It  may  always  be  inferred  that  they  are  dependent,  to  a  cer- 
tain degree,  upon  constitutional  depravity,  debility  and  exhaustion  being 
usually  marked.  Stimulants,  quinin,  iron,  and,  later  on,  codliver-oil  are 
usually  required.  An  excellent  plan  of  stimulation  is  to  administer  a  milk- 
punch  or  eggncg,  with  3  grains  cf  qu'nin,  every  two  cr  three  hours,  in  ad- 

^  Bromin  was  highly  recommended  by  the  late  Dr.  F.  H.  Hamilton  in  hospital 
gangrene. 


TREATMENT    OF    CHANCEOID.  307 

dition  to  a  liberal  dietary.  Iron  and  strychnia  are  often  serviceable,  and, 
if  pain  or  restlessness  be  marked,  opinm  should  be  given.  According  to 
Ricord  and  Kodet,  opium  has  a  special  effect  in  these  cases.  The  former 
highly  indorses  the  internal  administration  of  potassio-tartrate  of  iron  as 
a  specific  for  phagedenic  chancroid,  it  being  termed  by  him  "the  born 
enemy  of  phagedena."^ 

After  the  parts  have  become  thoroughly  cicatrized  it  may  be  necessary 
to  trim  off  ragged  edges  of  prepuce  left  by  the  gangrenous  process,  or  the 
dorsal  incision  for  phimosis,  thus  completing  circumcision. 

In  some  cases  of  chancroid,  extensive  cauterization  is  not  to  be  thought 
of:  e.g.,  in  severe  anal  chancroid  and  sores  located  in  close  proximity  to 
large  blood-vessels.  Under  these  circumstances  the  application  of  such 
remedies  as  the  potassio-tartrate  of  iron,  pyrozone,  iodoform,  charcoal,  and 
carbolic  or  salicylic  acid  is  about  all  that  can  be  done.  Fortunately,  how- 
ever, such  chancroids  are  rare.  The  utmost  cleanliness  is  required,  and 
gauze  sprinkled  with  iodoform  should  be  constantly  kept  between  the  op- 
posing surfaces.    It  may  be  necessary  to  stretch  the  sphincter. 

Obstinate  cases  of  chronic  phagedenic  and  serpiginous  chancroid  cf 
the  vulva  are  best  treated  by  the  actual  cautery.  This  is  to  be  applied  from 
time  to  time  in  the  hope  of  stimulating  repair.  Unfortunately  this  hope  is 
but  rarely  realized,  as  may  be  seen  by  a  visit  to  the  wards  of  any  large  hos- 
pital devoted  to  venereal  diseases.  Broken-down  prostitutes  with  this  form 
of  disease  are  almost  always  to  be  found  in  such  institutions.  It  is  not  un- 
usual for  the  surgeon  to  go  through  the  entire  range  of  antiseptics,  astrin- 
gents, and  caustics  in  his  search  for  a  remedy  for  these  cases.  Bumstead 
recommended  dry  persuljihate  cf  iion  in  such  chronic  chancroids,  but  the 
author  has  failed  to  see  any  perceptible  benefit  from  its  use. 

The  constitutional  treatment  is  the  most  important.  Attention  should 
be  paid  to  general  h3^giene  and  diet.  Stimulants,  iron,  quinin,  codliver- 
oil  and  other  tonics  are  always  required,  and  are,  as  a  rule,  more  beneficial 
than  any  form  of  local  treatment. 

As  a  rule,  the  use  of  mercury  in  chancroid  is  injurious,  but  in  syph- 
ilitic subjects  it  is  necessary — most  often  in  tonic  doses.  Exceptional  cases 
of  simple  chancroid  that  tend  to  chronicity  heal  quite  rapidly  under  small 
doses  of  mercury.  In  several  cases  of  this  kind  under  the  author's  observa- 
tion syphilis  was  excluded  by  the  contraction  of  chancre  followed  by  sec- 
ondary symptoms  several  months  after  the  chancroid  had  disappeared. 

In  nearly  all  cases  of  chancroid  of  whatever  type,  frequent  prolonged 
hot  sitz-baths  are  of  great  service.  This  particular  method  of  applying 
moist  heat  seems  to  be  of  especial  value  in  chancroid  and  its  attendant 
adenitis. 


^  The  author's  preceptor,  the  late  Dr.  F.  B.  Norcom,  of  Chicago,  himself  a  pupil 
of  Ricord's,  relied  almost  exclusively  upon  opium  in  phagedena. 


CHAPTEE  XIII. 

Vexeeeal  Adenitis,  oe  Bubo. 

The  subject  of  bubo  has  been  deemed  wortlij^  of  separate  consideration, 
although  it  rarel}',  if  ever,  exists  as  a  primary  condition.  ISTotwithstanding 
the  fact  that  it  is  most  often  a  complication  due  to  secondary  infection  from 
one  or  the  other  of  the  local  manifestations  of  venereal  disease,  it  never- 
theless frequently  occurs  in  conditions  of  a  simple,  non-specific,  and  even 
non-venereal  character.  The  only  conditions  necessary  for  its  development 
are  (1)  some  sort  of  infectious  inflammation  situated  in  tissues  the  lym- 
phatics of  which  are  tributary  to  lymphatic  glands  in  the  immediate  vicin- 
ity; (2)  the  absorption  of  the  products  of  the  aforesaid  infectious  process 
and  its  conveyance  by  the  lymphatics  to  the  glands;  (3)  a  degree  of  viru- 
lency  of  the  infectious  materials  too  great  to  be  overcome  by  the  tissues  of 
the  lymphatic  glands  to  which  the  infection  is  conveyed. 

The  term  hiiho  is  generally  applied  only  to  those  glandular  enlarge- 
ments occurring  in  the  inguinal  or  femoral  regions,  irrespective  of  cause, 
and  which  are  usually  accepted  as  an  evidence  of  venereal  infection  of  one 
kind  or  another.^  This  popular  interpretation  of  the  term  is  unfortunate, 
as  the  affection  is  often  due  to  causes  of  a  simple  and  innocent  nature  and 
may  involve  the  lymphatics  in  any  situation.  The  term  adenitis  is  better, 
and  may  with  equal  propriety  be  applied  to  glandular  swellings  occurring 
in  the  groin,  femoral  region,  axilla,  or  neck,  irrespective  of  their  origin, 
and  signifies  a  glandular  inflammation,  simple  or  specific.  In  genito-urinary 
practice  we  deal  chiefly  with  the  form  of  adenitis  that  occurs  in  the  groin 
or  femoral  region,  or  in  other  situations  when  due  to  extragenital  venereal 
lesions. 

The  consideration  of  bubo  is  of  the  greatest  importance  as  bearing 
upon  diseases  of  a  general  surgical  character,  and  a  careful  study  of  the 
subject  will  enable  the  student  to  understand  other  forms  of  adenitis  that 
are  so  often  met  with  in  general  practice.  There  is  often  no  practical  dif- 
ference between  the  sup^Durative  axillary  adenitis  resulting  from  a  dissec- 
tion wound  or  other  injury  to  the  hand  and  a  suppurating  non-sj^philitic 
bubo,  and  a  knowledge  of  the  causes  and  proper  treatment  of  the  one  is 
apt  to  be  of  service  in  the  management  of  the  other. 

Adenitis  is  one  of  the  most  interesting  of  all  surgical  phenomena,  the 
more  especially  as  it  is,  so  to  speak,  a  manifestation  of  the  special  ph3^siologic 
function  of  the  lymphatic  glands.  The  lymphatic  system  is  interposed  be- 
tween the  venous  and  vascular  systems,  and  is  designed  for  the  collection 
and  return  to  the  circulation  of  any  superfluous  nutritive  material  that  may 


^  Bilbo  ( jBovPov  ) ,  groin. 

(308) 


PATHOGENY   AXD    CLASSIFICATIOX    OF    T  EXEEEAL    ADENITIS.  309 

accumulate  in  the  tissues.  The  fine  lymjDliatic  vessels  are  seemingly  hungry 
for  nutritive  substances  at  all  times,  but  unfortunately  they  do  not  possess 
the  power  of  discriminating  between  beneficial  or  innocuous  and  injurious 
substances.  Any  soluble  or  finely-divided  organic  material  may  therefore 
be  taken  up  by  the  lymphatics  and  conveyed  to  the  nearest  glands,  and 
thence  even  to  the  general  system  by  way  of  the  veins,  heart,  and  arteries, 
inducing  morbid  changes  in  the  blood  and  various  solid  tissues.  This  is 
well  illustrated  in  general  or  systemic  pus-infection,  or,  as  it  was  formerly 
termed,  pyemia.  This  peculiar  property  of  the  lymphatics  is  well  marked 
in  cachectic  or  debilitated  patients  in  whom  there  is  a  decided  systemic 
demand  for  an  increase  of  nutritive  material.  As  is  well  known,  the  aver- 
age results  of  dissection  wounds  in  robust  and  debilitated  students  are 
widely  different.  One  may  have  either  no  morbid  manifestations  at  all 
or  such  as  are  mainly  local,  while  the  other  is  quite  apt  to  have  a  severe 
or  even  fatal  result.  This  rule  will  also  apply  to  venereal  adenitis,  there 
being  a  marked  difference  in  the  suscejDtibility  to  glandular  complica- 
tions of  different  patients  aff'ected  with  lesions  of  a  similar  nature.  The 
lymphatic  glands,  fortunately,  are  interposed  between  the  general  system 
and  the  atria  of  infection  in  surgical  affections,  and,  in  a  general  way, 
often  jDrotect  the  human  organism  against  serious  or  even  fatal  results  from 
the  absorption  of  poisons.  By  undergoing  inflammatory  reaction,  the  glands 
interpose  a  barrier  of  plastic  exudate  to  the  further  progress  of  pathogenic 
germs  and  their  products,  which  by  suppuration  and  ulceration  are  finally 
eliminated.  The  well-known  odor  of  the  dissecting-room,  as  observed  in 
the  pus  from  axillary  abscesses  following  dissection  wounds,  is  ample  proof 
of  this.  In  some  patients,  and  with  some  infections,  this  glandular  reac- 
tion is  either  absent  or  slight,  and,  as  a  consequence,  systemic  disturbance 
occurs,  the  degree  of  reaction  being  mainly  dependent  upon  the  corrosive- 
ness  of  the  poison  and  the  plasticity  of  the  patient's  blood. 

It  is  probably,  therefore,  a  fortunate  circumstance  for  humanity  that 
the  infection  of  chancroid  causes  severe  adenitis  when  carried  to  tha  lym- 
phatic glands.  What  results,  if  any,  would  ensue  from  the  direct  introduc- 
tion of  chancroidic  secretion  into  the  veins  has  never  been  demonstrated  by 
experiment,  but  from  a  priori  considerations  one  would  naturally  expect 
quite  serious  trouble  from  such  inoculation.  The  chancroidic  process  is  a 
mixed  infection — whether  primarily  or  not — and  might  consequently  prove 
dangerous  if  thrown  into  the  general  circulation. 

As  seen  in  practice,  bubo  occurs  in  a  variety  of  forms,  which  may  be 
classified  as  follows: — 

1.  Simple  non-venereal  adenitis  dependent  upon  simple  lesions  of  the 
neighboring  tissues. 

3.  Simple  venereal  adenitis  dependent  upon  "specific"  lesions,  usually, 
but  not  necessarily,  of  the  genitals.  Simple  bubo  may  be  suppurative  or 
non-suppurative. 


310  VEXEKEAL    ADENITIS,    OK    BUBO.. 

3.  Virulent  adenitis  due  nnder  all  circumstances  to  chancroidic  infec- 
tion and  indicating  the  action  of  this  sjDCcial  form  of  irritant  upon  the  lym- 
phatic glands,  this  form  being  invariahh'  suppurative  and  quite  liable  to 
phagedena  and  gangrene. 

4.  Primary  sj'philitic  adenopathy. 

5.  Eecurrent  sjqjhilitic  bubo, — inguinal  or  femoral  adenoj^ath}', — a 
form  that  is  not  generally  recognized. 

6.  Subacute  adenitis,  or  chronic  adenitis,  primarily  of  venereal  origin, 
but  perpetuated  by  some  form  of  cachexia  or  diathesis.  Its  ehronicity  is 
most  likely  to  be  due  to  superadded  syphilis  or  tubercular  infection. 

In  general,  bubo  ma}'  be  classified  as  acute,  subacute,  and  "chronic; 
suppurative  and  non-suppurative. 

The-  two  varieties  of  simple  buljo  (simple  adenitis)  may  result  from 
any  inflammatory  lesion  of  tissues  contiguous  to,  or  draining  into,  lym- 
phatic glands.  A  "specific"  lesion  of  the  genitals  may  or  may  not  give  rise 
to  specific  Ijubo,  such  an  occurrence  depending  entirely  upon  the  absorption 
or  non-absorption  of  the  special  jjoison  of  the  primary  lesion;  but  it  is  none 
the  less  likely  to  give  rise  to  simple  bubo  from  the  conveyance  of  simple 
inflammatory  products,  or  the  products  of  mixed  infection,  to  the  contigu- 
ous glands.  Simple  bubo,  therefore,  may  be  due  to  chancroid,  chancre, 
balanitis,  herpes,  gonorrhea,  or  even  stricture.  It  has  been  known  to  occur 
as  a  result  of  genital  eczema,  eczema  of  the  leg,  erj^sipelas,  an  inflamed  corn, 
yaccination,  etc.  In  short,  any  inflammatory  or  infectious  process  involv- 
ing those  tissues  the  lymphatics  of  which  are  tributary  to  the  inguinal  or 
femoral  glands  is  apt  to  cause  bubo,  and  this  fact  should  be  remembered. 
It  is  probable,  moreover,  that  violent  strains  and  overexertion  in  some  sub- 
jects predispose  to  buba.  The  term  "sympathetic  bubo''  has  been  quite 
generally  applied  to  the  simple  form  of  the  affection,  but,  in  the  light  of 
our  present  pathologic  knowledge,  such  a  form  of  adenitis  is  not  to  be  ac- 
cepted. Wherever  bubo  develops  it  is  certain  that  either  infection,  simple 
or  specific,  has  been  carried  to  the  affected  gland  or  that  actual  injury 
to  the  gland  has  been  jDroduced  by  trauma,  which  trauma  is  followed  by 
infection.  The  only  possible  exception  to  this  rule  is  the  so-called  "scrofu- 
lous bubo."  and  even  in  this  form  some  injury  or  source  of  irritation  is 
usually  discoverable.  Oftentimes  the  alleged  strumous  bubo  is  really  tuber- 
cular. 

Simple  bubo  from  mixed  infection  is  quite  apt  to  suppurate,  but  need 
not  necessarily  do  so,  the  affection  differing  decidedly  in  this  respect  from 
the  virulent  form  of  adenitis. 

The  location  of  bubo,  whether  simple  or  specific,  depends  upon  the  situ- 
ation of  the  primary  lesion;  thus,  in  lesions  up:n  the  fingers,  the  axillary 
and  cubital;  in  lesions  of  the  genitalia,  legs,  and.  anus,  the  femoral  or  in- 
guinal; and  in  lesions  of  the  face,  the  pre-aural  or  submaxillary  glands  are 
most  likelv  to  be  affected.     Obviouslv,  the  inguinal  and  femoral  glands  are 


FEEQUENCY    OF    VENEEEAL    ADENITIS. 


311 


most  often  involved,  and,  as  chancroid  is  the  severest  and  most  typicall}' 
virulent  of  the  local  inflammations  of  the  genitalia,  this  lesion  is  more  often 
than  any  other  responsible  for  bubo,  it  being  estimated  that  over  one-third 
of  the  cases  of  chancroid  are  complicated  by  adenitis.  Simple  bubo,  on 
account  of  the  numerous  infectious  conditions  that  are  likely  to  give  rise 
to  it,  is  more  frequent  than  the  virulent  form.  The  relative  frequency  of 
bubo  of  all  forms  in  men  and  women  affected  by  chancroid  is  about  two  to 
one  greater  in  the  male,  suppuration  being  also  twice  as  frequent  as  in 
women.     This  is  ascribed  by  Ziessl  to  the  fact  that  the  male  sex  is  more 


Hr.Qt 


Fig.  98. — Double  chancroidic  bubo  after  spontaneous  evac-uation. 
Showing  hyperplasic  infected  glands. 


active  and  the  parts  are  consequently  more  exposed  to  pressure  and  local 
irritation.  It  may  also  be  explained  by  the  fact  that  chancroids  in  women 
are  apt  to  be  better  protected  from  local  irritation  by  friction  in  walking. 
Last,  but  by  no  means  least,  the  frequency  of  alcoholism  in  men  as  com- 
pared with  women  is  to  be  considered.  Chancroids  of  the  mucous  mem- 
brane are  more  likely  to  be  complicated  by  adenitis  than  those  occurring 
upon  the  skin,  as  might  be  expected  from  the  relatively  greater  facility  of 
absorption  of  germ-and-toxin-laden  secretions  by  mucous  tissues. 

The  glands  aff'ected  are  the  same  in  both  simple  and  specific  bubo, 
there  being  a  decided  predilection  for  the  central  inguinal  lymphatics  upon 


312  VENEEEAL  ADEXITIS,  OE  BUBO. 

the  side  corresponding  to  the  local  lesion,  although  cases  of  crossed  bnbo 
are  seen  in  which  the  opposite  side  is  affected,  or  both  s'des  att&cked  simul- 
taneously. In  rare  instances  simple  bubo  may  occur  upon  one  side  and 
virulent  upon  the  other.  The  infection  often  stops  at  the  gland  first  af- 
fected in  both  simple  and  virulent  bubO;,  the  process  being  more  general  in 
those  forms  dependent  upon  such  constitutional  conditions  as  syphilis, 
struma,  and  tuberculosis. 

The  time  of  appearance  of  bubo  does  not  bear  a  constant  relation  to 
the  development  and  progress  of  the  primary  lesion;  cases  of  bubo  follow- 
ing chancroid  are  jnet  with  in  which  the  sore  is  completely  healed  before 
the  adenitis  develops.     Such  cases,  however,  are  quite  exceptional. 

Chancroid  occurring  in  tissues  richly  supplied  with  lymphat'cs  are 
most  apt  to  be  attended  by  bubo,  this  being  especially  noticeable  in  those 
occurring  beside  the  frenum  preputii  in  the  male. 

The  possibility  of  the  occurrence  of  idiopathic  bubo  has  been  affirmed 
by  some,  but  denied  by  the  majority  of  observers.  The  author  inclines  to 
the  belief  that,  while  simple  adenitis  in  the  inguinal  and  femoral  glands  is 
not  so  rare  as  has  been  generally  supposed,  there  is  always  some  source  of 
infection,  latent  or  active.  It  is  probable  that  the  majority  of  surgeons  have 
met  with  a  certain  number  of  cases  in  which  no  causal  lesion  has  been  dis- 
coverable; it  is  certain  that  comparatively  slight  causes  may  produce  ad- 
enitis in  debilitated,  strumous,  or  syphilitic  subjects,  and  this  is  quite  as 
likely  to  afilect  the  inguinal  or  femoral  glands  as  those  in  other  situations; 
indeed,  the  necessary  movements  of  the  parts  about  the  flexure  of  the  thigh 
especially  favor  inflammation  in  this  locality.  Notwithstanding  the  occur- 
rence of  such  apparently  spontaneous  attacks  of  adenitis,  it  is  probable  that 
in  all  cases  the  explanation  is  infection,  either  recent  or  remote,  of  some  of 
the  tissues  tributary  to  the  affected  glands.  The  urethra  is  more  frequently 
the  source  of  such  infection  than  is  generally  believed.  Latent  infection  of 
the  glands  themselves  may  exist,  and  be  developed  into  active  infection  by 
some  accidental  injury. 

The  older  authorities  of  the  French  school  laid  great  stress  upon  a  form 
of  alleged  spontaneous  specific  bubo:  the  hubon  d'emUee.  This  was  sup- 
posed to  arise  b}''  the  absorption  of  ehancroidic  or  syjDhilitic  poison  through 
the  unbroken  skin  or  mucous  membrane  occurring  without  a  preceding 
sore.  This  view,  involving,  as  it  necessarily  must,  the  conveyance  of  germ- 
infection  directly  to  the  lymphatic  glands  via  the  absorbents,  and  the  ex- 
citation of  secondary  glandular  reaction  without  primary  local  changes,  is 
now  held  to  be  untenable,  especially  in  the  case  of  chancroid.  The  hnho?i 
d'emblee  has,  however,  been  advocated  by  such  eminent  authorities  as 
Casenave  and  Diday,  though  disputed  by  Eicord  and  Fournier.  The  major- 
ity of  modern  S3'philographers  deny  its  existence. 

In  some  cases  of  true  syphilis  no  manifestations  of  the  disease  are 
observed  prior  to  the  appearance  of  bubo, — i.e.,  primary  adenopathy, — but 


SYMPTOMS  OF  VENEEEAL  ADENITIS.  313 

even  in  such  instances  an  initial  lesion  has  probably  existed,  and  has  either 
been  overlooked  or  has  disappeared  prior  to  examination,  the  initial  sore 
being  in  some  cases  so  slight  as  to  readily  disappear,  or  imperceptible  except 
under  close  inspection  of  the  genitals.  Cases  of  this  kind,  and  of  mild 
chancroid  that  has  healed  prior  to  examination,  but  has  nevertheless  been 
followed  by  bubo,  probably  most  often  constitute  the  so-called  dubon  d/emblee, 
for  it  is  well-nigh  certain  that  local  changes  of  greater  or  less  degree  of 
severity  always  follow  infection  by  syphilitic  or  corrosive  chancroidal  poison. 

In  some  cases  of  apparently  idiopathic  suppurative  bubo,  the  test  of 
autoinoculation  may  settle  the  question  of  the  pre-existence  of  chancroid. 
Should  autoinoculation  prove  successful,  it  will  demonstrate  the  existence 
and  character  of  a  local  lesion  that  had  appeared  and  healed  shortly  before 
the  appearance  of  the  bubo. 

Symptoms.  — ■  The  symptoms  of  simple  inflammatory  bubo  are  quite 
characteristic.  The  first  manifestation  of  the  disease  consists  of  a  feeling 
of  soreness  in  the  groin,  such  as  might  be  produced  by  a  violent  strain.  On 
inspection,  one  or  more  small,  round,  or  ovoid  indurated  swellings  are  found 
in  the  groin  or  femoral  region.  These  are  usually  quite  tender  to  the  touch, 
and  cause  considerable  pain  in  walking,  although  at  first  freely  movable 
upon  the  sublying  tissues.  In  some  instances  there  is  slight  febrile  move- 
ment. In  many  cases  the  inflammation  may  be  aborted  at  this  stage  by 
proper  management,  and  resolution  will  occur  quite  promptly;  but  in  the 
majority  the  swelling  and  pain  rapidly  increase,  the  swelling  of  the  glands 
becomes  blended  in  that  of  the  surrounding  tissues,  and  the  skin  becomes 
adherent  at  one  or  more  points.  After  a  variable  time  a  spot  of  softening 
develops  and  the  abscess  finally  breaks,  discharging  a  more  or  less  creamy 
and  healthy-looking  pus  for  a  few  weeks,  and  healing  quite  promptly  under 
favorable  circumstances.  In  by  far  the  greater  number  of  cases,  however, 
healing  is  apt  to  be  slow.  There  are  few  patients  who  do  not  attempt  to 
attend  to  their  ordinary  duties  while  at  the  same  time  endeavoring  to  obtain 
a  cure  for  the  bubo.  This  is  the  explanation  of  the  majority  of  cases  of 
chronic  simple  bubo.  The  lack  of  rest  is  frequently  supplemented  by  de- 
bility, syphilitic  or  other  cachexia,  and  intemperance,  the  last-named  factor 
being  second  only  to  a  lack  of  rest  in  retarding  healing.  Very  often  the 
conditions  just  enumerated  result  in  the  formation  of  sinuses  that  can  be 
cured  only  by  operation. 

The  constitutional  symptoms  in  suppurative  bubo  are  those  of  simple 
suppuration,  and  the  formation  of  pus  may  therefore  be  heralded  by  a  chill 
of  greater  or  less  severity. 

The  course  of  simple  bubo  in  strumous  or  cachectic  patients  is  apt  to 
be  particularly  annoying,  constituting  subacute  or  chronic  indolent  bubo. 
Instead  of  an  acute  inflammation  affecting  one  or  two  glands,  a  number 
of  glands  are  likely  to  be  involved,  with  slowly-progressing,  indolent  en- 
largement and  chronic  suppuration.     The  glands  become  matted  together 


314  YEXEEEAL  ADENITIS,  OE  BUBO. 

in  a  brawny  indurated  mass,  sometimes  edematous,  sometimes  producing, 
b}'  circulatory  obstruction,  edema  of  the  genitals.  After  an  indefinite  time 
the  periglandular  connective  tissue  breaks  down  into  a  thin,  unhealthy, 
ichorous  pus,  after  which  the  abscess,  if  unopened,  will  sooner  or  later 
break  spontaneously.  The  skin  about  such  abscesses  is  thinned  and  bluish, 
its  nutrition  being  profoundly  impaired.  Burrowing  of  pus  in  various 
directions,  with  consequent  formation  of  sinuses  with  hard  pseudocartilagi- 
nous  tracks,  may  result,  yielding  a  discharge  that  sometimes  persists  for 
years.  When  the  abscess  is  first  opened  in  such  cases,  the  glands  will  be 
found  to  be  entire  and  circumscribed.  Jutting  out  from  the  floor  or  sides 
of  the  cavity,  showing  that  the  inflammation  in  such  cases  is  chiefly  peri- 
glandular. In  such  cases  the  glands  are  primarily  the  seat  of  small  miliary 
abscesses,  one  or  more  of  which  break  into  the  periglandular  tissues,  infect- 
ing them  and  producing  abscess.  The  conformation  of  the  glands  is  not 
altered,  and  there  is  often  no  evidence  of  suppuration  in  them  at  the  time 
the  periadenitic  pus  is  evacuated. 

Miliary  glandular  abscesses  are,  in  the  authors  opinion,  the  invariable 
cause  of  periadenitis  in  bubo.  Even  in  simple  bubo  such  abscesses  occur 
very  early.  The  author  has  found  them  as  early  as  the  third  day  after  the 
development  of  a  gonorrheal  adenitis.  This  fact  is  the  principal  argument 
in  favor  of  early  extirpation  of  the  glands  in  bubo,  however  simple  the  form. 
Good  results  are  not  to  be  expected,  as  a  rule,  after  periadenitis  has  occurred. 
The  glands  may  subsequent!}^  break  down  into  pus,  but  more  often  they 
liecome  hyperplastic  and  the  seat  of  fungoid  granulations  that  prevent  heal- 
ing. Sometimes  they  hypertrophy  to  such  an  extent  as  to  completely  fill 
the  abscess-cavity,  forming  a  large  projecting  fungoid  mass,  in  which  case 
healing  never  occurs  without  surgical  interference.  Suppuration  does  not 
always  occur  in  indolent  bubo,  for  the  glands  may  remain  as  comparatively 
painless,  sluggish  swellings  indefinitely. 

The  pus  of  simple  bubo,  whether  acute  or  chronic,  is  never  autoin- 
oculable  in  the  specific  sense,  nor  is  the  process  apt  to  be  complicated  by 
phagedena;    erysipelas  and  gangrene,  however,  are  possible  complications. 

ViEULE^fT  Bubo. — This  has  been  fallaciously  termed  "the  bubo  of  ab- 
sorption," from  the  fact  that  absorption  of  the  secretion  of  chancroid  is 
necessary  to  its  production.  This  term  is  obviously  misleading,  for  simple 
bubo  is  due  to  absorption  of  pus-microbes  and  their  toxic  products,  as  de- 
velojDed  in  simple  inflammation.  The  term  "chancroidic  bubo"  is  not  ac- 
ceptable, for  the  reason  that  chancroid  may  produce  simple  bubo  by  the 
absorption  of  the  products  of  mixed  infection,  independently  of  the  specific 
character  of  the  fons-origo  et  mali. 

This  form  of  bubo  usualty  affects  a  single  gland  ujDon  one  side,  and  is 
not  readily  distinguished  from  the  simple  acute  form  until  the  pus  is  dis- 
charged and  autoinoculation  can  be  practiced  or  the  resultant  lesion  in  the 
groin  assumes  chancroidic  characters.    In  a  general  way,  it  may  be  said  that 


VIBULENT    BUBO.  315 

viinilent  bubo  is  a  more  active  process  and  suppurates  much  more  quickly 
than  the  simj^le  variety,  but  these  characters  are  by  no  means  to  be  relied 
upon  for  a  diagnosis.  There  is  one  j)eculiar  feature  of  virulent  bubo  that 
it  is  well  to  bear  in  mind,  viz.:  its  liabilitv  to  aii  accompanying  periadenitis 
of  a  simple  suppurative  character.  Under  such  circumstances,  the  first  pus 
discharged  from  the  abscess  is  unirritating  in  character  and  not  autoin- 
oculable,  while  that  which  is  evacuated  later  on  from  the  gland  proper  is 
highly  corrosive  to  the  tissues  and  typically  autoinoculable.  This  circum- 
stance explains  how  some  cases  of  apparently  simple  suppurative  bubo  un- 
dergo subsequent  transformation  into  the  virulent  form  of  the  affection.^ 

Soon  after  a  virulent  adenitis  ruptures  or  is  inc'sed,  the  lesion  assumes 
the  characters  of  ordinary  chancroid.  In  favorable  cases  the  tissues  become 
so  matted  together  about  the  abscess  that  it  remains  circumscribed,  but 
occasionally  the  surrounding  structiires  are  so  loose  that  extensive  and  de- 
structive burrowing  occurs,  forming  sinuses  and  pockets  that  may  last  for 
3'ears,  perhaps  for  life. 

Phagedena  may  attack  a  viruLnt  buljo.  Phageclen'c  genital  chancroid 
is  not  necessary  for  its  production,  simple  chancroid  being  frequently  fol- 
lowed by  phagedenic  bubo.  When  phagedena  does  attack  a  bubo,  it  is  quite 
likely  to  assume  the  serpiginous  form.  This  extends  upward  over  the  ab- 
domen by  preference,  but  when  the  process  reaches  the  walls  of  the  chest, 
which  appear  to  be  unfavorable  soil  for  its  progression,  it  will  usually  ad- 
vance in  the  other  direction  and  descend  along  the  thigh. 

Some  cases  of  phagedena,  notably  the  serpiginous  form,  will  progress 
with  greater  or  less  rapidity  in  spite  of  the  best  of  treatment,  and  others, 
after  the  phagedena  has  been  checked  and  the  sore  is  very  nearly  healed, 
will  suddenly  take  on  phagedenic  action.  Simple  bubo  may  do  the  same 
thing,  in  rare  instances.  The  author  recalls  one  case  occurring  in  the  wards 
of  the  NeAV  York  Charity  Hospital  in  which  the  bubo  was  apparently  nearly 
closed  and  was  granulating  finely,  when  gangrenous  phagedena  set  in  and 
extended  over  nearly  half  the  abdomen  before  it  could  be  checked.  By  free 
stimulation  and  a  nourishing  diet,  with  the  local  application  of  the  carbo- 
sulphuric  paste,  the  process  was  finally  stopped,  but  not  until  a  large  area 
of  the  external  oblique  muscle  had  been  destroyed  and  even  the  sublying 
muscles  attacked.  This  case  was  primarily  one  of  virulent  bubo,  but  had 
not  been  phagedenic,  and  at  the  time  the  phagedena  set  in  was  practically 
a  simple  bubo  in  j^rocess  of  granulation. 

There  is  one  form  of  chronic  bubo  that  merits  especial  attention.  This 
is  the  variety  that  accompanies  the  form  of  chronic  chancroid  erroneously 
termed  lupoid  of  the  vulva,  or,  in  the  male,  chronic  phagedena.    This  form 


^  Virehow,  in  his  "Cellular  Pathology.'"  calls  attention  to  the  fact  that  the  poison 
is  found  in  the  substance  of  the  gland,  and  not  in  the  surrounding  tissues.  Ricord 
first  directed  attention  to  this  peculiar  feature  of  virulent  bubo. 


316 


VENEEEAL  ADENITIS,  OR  BUBO. 


of  bubo  is  identic  in  its  general  characters  with  the  lesion  of  the  genitals 
that  it  accompanies,  presenting  an  elevated,  hyperplasic  mass  of  tissue  of 
greater  or  less  extent,  with  an  unhealthy  pultaceous  or  worm-eaten  appear- 
ance of  its  surface,  and  secreting  an  ichorous  fluid.  The  disease  extends 
very  slowly,  if  at  all,  after  having  attained  a  certain  size,  the  process  having 
meanwhile  become  .continuous  in  many  cases  with  the  genital  ulcer.  There 
are  apt  to  be  several  of  the  buboes,  either  separate  and  distinct  or  connected 
by  ulceration.  Such  cases  are  very  apt  to  be  of  an  hemorrhagic  nature  in 
pregnant  females.    This  severe  form  of  chronic  bubo  is  rarely,  if  ever,  seen 


Fig.  99. — Phagedenic  bubo. 


in  private  practice,  being  found  in  broken-down  hospital  cases.  It  will 
often  defy  the  best  measures  of  treatment  and  finally  wear  the  patient  out. 
As  has  been  already  stated  in  connection  with  the  physiology  of  the 
lymphatic  capillaries  and  glands,  virulent  adenitis  does  not  infect  the  gen- 
eral system.  This  fact  is  jDCCuliar,  for,  from  a  priori  considerations,  we 
would  expect  that  a  process  so  intensely  infectious  locally  and  presenting  by 
its  extent  such  favorable  opportunities  for  absorption  of  poisonous  materials 
Avould  be  apt  to  produce  constitutional  infection  of  greater  or  less  degree. 
Not  only  is  the  contrary  the  case,  but  virulent  adenitis,  per  se,  rarely,  if  ever, 
leads  to  septemia.  Indeed,  the  author  cannot  recall  a  single  case  of  such 
septic  absorption.     In  phagedenic  adenitis,  especially,  it  would  seem  that 


VIRULENT    BUBO.  317 

there  should  be  danger  of  secondary  infection.  Such,  however,  is  not  the 
case.  On  the  other  liand,  in  the  gangrenous  form  of  the  affection  a  greater 
or  less  degree  of  septic  infection  is  usual,  but  this  is  independent  of  the 
alleged  specificity  of  the  bubo. 

Stimulated  by  the  researches  of  the  eminent  Chauveau,  in  his  study  of 
the  effects  of  heat  in  weakening  and  modifying  organic  poisons,  Aubert 
experimented  some  years  ago  with  the  virus  of  chancroid,  with  the  view  of 
explaining  some  of  its  peculiarities,  with  especial  reference  to  its  non-con- 
stitutional character.     The  experiments  were  conducted  as  follows^: — 

Chancroidic  virus  was  taken  from  different  hospital  patients  and  placed  in 
vaccine-tubes,  some  of  which  were  then  subjected  to  various  degrees  of  heat,  while 
the  remainder  were  preserved  unchanged. 

Inoculations  were  performed  with  the  heated  and  the  non-heated  virus,  respect- 
ively, and  their  results  compared. 

In  this  way  it  was  found  that  the  virus  becomes  powerless  when  heated  to  be- 
tween 37°  and  38°  C. — the  average  temperature  of  the  interior  of  the  human  body. 

As  a  deduction  from  these  experiments,  Aubert  concludes  that  he  has 
explained  the  following  points  in  the  clinical  history  of  soft  chancre^: — 

1.  The  seeming  impenetrability  of  the  sj^stem  by  the  virus  of  chancroid,  as  evi- 
denced by  the  non-occurrence  of  internal  ulcers  and  pelvic  buboes.  The  long-estab- 
lished fact  that  chancroidic  infection  never  spreads  to  the  interior  tissues  or  beyond 
the  superficial  glands  can  only  be  accounted  for  on  the  ground  of  heat.  Admitting 
this  we  can  scarcely  conceive  the  possibility  of  a  pelvic  abscess  of  venereal  origin 
except  in  a  subject  whose  central  temperature  had  previously  been  lowered  by 
exposure  to  long-continued  and  intense  cold.  But  if  the  infectious  matter  were  able 
to  withstand  a  heat  of  40°  or  45°  C,  there  would  be  nothing  to  prevent  its  per- 
meating the  entire  organism  and  furnishing  the  most  fearful  manifestations  of  its 
power. 

2.  The  occurrence  of  bubo,  whether  chancroidic  or  inflammatory,  solely  in  the 
superficial  glands.  All  the  glands — superficial  and  deep — are  alike  in  structure  and 
function;  but  the  former,  owing  to  their  situation,  preserve  a  lower  temperature,  and 
this  is  the  only  conceivable  reason  why  they  alone  are  affected  by  bubo. 

3.  The  brief  duration  of  chancroids  on  the  cervix  uteri,  and  the  rapid  changes 
they  undergo,  are  facts  that  should  be  considered  from  the  same  point  of  view;  as, 
also, 

4.  The  limitation  of  chancroid  of  the  anus  to  the  inferior  portion  of  the  latter. 

5.  The  relative  frequency  of  simple  inflammatory  bubo,  which  occurs  almost  as 
often  as  the  chancroidic  form.  It  is  a  familiar  fact  that  the  same  primary  sore  will 
give  rise  sometimes  to  a  chancroidic  bubo  yielding  inoculable  pus  and  sometimes  to  a 
simple,  non-infectious  swelling. 

I  regard  all  secondary  buboes  as  chancroidic  in  their  beginning,  but  think  that 
an  attack  of  fever  will  operate  to  convert  any  such  bubo  into  one  that  is  simply  inflam- 
matory. 


^P.  Aubert,  Lyon  Medicate,  August   12,   1883. 

^Aubert  tei'ms  the  chancroid  "chancre."     The  author  has  changed  the  term  to 
avoid  confusion. 


318  VEXEEEAL    ADEXITIS,    OR   BUBO. 

6.  Cure  of  phagedena  by  erysipelas.  Erysipelas  causes  an  elevation  both  of  the 
central  and  local  temperature,  which  may  suffice  to  destroy  the  virulence  of  chan- 
eroidie  pus  and  to  transfonu  the  spreading  ulcer  into  a  simple  one. 

7.  Cure  of  chancroid  by  gangrene.  The  gangrenous  process  is  uniformly  accom- 
panied by  intense  fever — sometimes  passing  into  typhus — and  itself  results  from  a 
high  grade  of  tissue-inflammation. 

8.  The  difference  in  the  results  of  inoculation  in  different  regions.  This  is  well 
known  to  experimenters,  especially  as  connected  with  chancroid  of  the  face. 

Eeasoning  from  the  premises  above  indicated,  Aubert  believes  that  heat 
in  the  form  of  local  applications  and  the  prolonged  nse  of  hot  sitz-baths  is 
a  specific  for  chancroid  and  virnlent  bubo. 

Anbert's  theory  is,  to  say  the  least,  ingenious,  and  it  is  unfortunate  that 
there  should  be  any  ambiguity  in  his  statements  resulting  from  looseness  of 
nomenclature.  As  is  well  known,  the  system  is  not  impenetrable  to  the 
virus  of  true  chancre,  and  the  interior  tissues  and  glands  are  always  involved 
sooner  or  later.  At  the  time  of  the  occurrence  of  general  adenopathy,  how- 
ever, ulceration  or  necrosis  of  tissue  is  exceptional  in  the  natural  history  of 
the  disease.  In  the  case  of  chancroid,  the  lymphatic  glands,  as  already 
indicated,  seem  to  act  as  a  physiologic  barrier  to  the  internal  progression 
of  the  disease.  This  is  also  true  of  syphilis,  but  in  the  latter  disease  the 
resistance  of  the  glands  is  overcome  in  a  short  time,  and  the  infecting  cells 
gradually  invade  the  deeper  structures.  In  the  case  of  chancroid  the  poison 
so  irritates  the  glands  that  acute  inflammation  with  its  accompanying  ex- 
udate occurs,  and  blocks  the  farther  progression  of  the  poison,  in  all  prob- 
ability by  exudate  pressing  upon  the  absorbents,  thus  temporarily  check- 
ing their  functions.  By  the  time  this  pressure  has  been  removed  and  the 
exudative  material  has  disappeared  by  resolution  and  suppuration,  the  ab- 
scess has  been  evacuated,  either  by  the  knife  of  the  surgeon  or  by  spon- 
taneous discharge,  and  later  on  the  specificity  of  the  infection  becomes  ex- 
hausted, as  it  invariably  does  in  the  natural  course  of  the  disease.  An  area 
of  inflammatory  infiltration  of  greater  or  less  extent  surrounds  a  virulent 
bubo  for  some  little  time  after  the  specificity  of  the  discharge  has  disap- 
peared. It  will  be  found  that  the  infection  of  chancroid  tends  to  exhaust 
itself  by  the  inoculation  of  successive  tissues,  and  it  is  probable  that  it  thus 
finally  loses  its  power  of  extension  along  the  lymphatics.^  The  infection 
then,  in  all  probability,  becomes  modified,  so  far  as  its  affinity  for  lymphatics 
is  concerned,  in  the  glands  first  affected.  It  is  impossible  to  say  how  much 
influence  the  temperature  of  the  deeper  glands  may  have  in  opposing  the 
progress  of  the  infection,  but  it  does  not  seem  possible  that  the  difference 
in  temperature  of  the  superficial  and  deep  tissues  of  the  body  is  sufficient  to 
determine  the  non-susceptibility  of  the  latter.  It  is  highly  improbable  that 
the  conditions  to  wdiich  Aubert  subjected  his  virus  in  the  vaccine-tubes  were 


^  Some  of  the  experiments  conducted  in  Boeck's  method  of  syphilization  have 
demonstrated  this  fact. 


VIRULEXT    BUBO.  319 

at  all  similar  to  those  that  prevail  when  poisons  are  introduced  into  the 
animal  body. 

The  short  duration  of  chancroids  of  the  cervix  nteri  is  explained  by 
the  relative  density  of  the  tissues  of  this  region  and  the  sparsity  of  con- 
nective tissue  and  lymphatics  (ccnd'tions  which  form  very  unfavorable  soil 
for  the  development  of  chancroid),  rather  than  by  the  high  temperature  of 
the  part. 

That  erysipelas  and  gangrene  destroy  the  infection  of  chancroid  by 
virtue  of  the  elevated  temperature  which  they  produce  is  hardly  a  fair 
proposition.  Whether  the  tissues  are  so  modified  by  these  diseases  that  they 
will  no  longer  give  sustenance  to  chancroid,  or  the  germs  and  toxins  of 
these  diseases  are  inimical  to  the  life  of  the  organism  which  it  is  fair  to 
assume  is  the  essential  element  of  chancroid,  would  be  difficult  to  deter- 
mine, but  either  view  of  the  case  is  more  philosophic  than  the  deductions 
of  Aubert.  This  particular  point  has  been  expatiated  upon  because  of  the 
belief  that  it  is  one  of  the  most  interesting  features  in  the  life-history  of 
the  infection  of  chancroidic  ulcers  and  bubo.  So  far  as  the  local  use  of 
heat  is  concerned,  it  is,  irrespective  of  any  theory  of  its  action,  an  excellent 
measure  of  treatment,  and,  although  it  is  not  in  any  sense  a  specific,  it  is 
clinically  well  worthy  of  the  praise  that  our  overenthusiastic  experimenter, 
Aubert,  has  given  it. 

It  is  unnecessary  at  this  time  to  dwell  particularly  upon  primary  syph- 
ilitic bubo,  as  it  is  rarely  troublesome  and  is  important  only  as  a  local  mani- 
festation of  a  constitutional  disease,  rarely  calling  for  special  local  meas- 
ures of  treatment.  Whenever  it  is  prominent  per  se,  it  is  from  superadded 
simple  pus-infection,  or  virulent  infection  from  complicating  chancroid, 
and  not  from  its  syphilitic  character.  The  more  typically  syphilitic  the 
bubo,  the  more  innocuous  it  is.  Syphilitic  bubo  rarely  suppurates,  and  then 
only  as  a  result  of  complicating  infection,  pyogenic,  tubercular,  or  chan- 
croidic. Its  special  characters  will  receive  attention  in  connection  with  the 
subject  of  primary  syphilis. 

There  is  a  form  of  syphilitic  bubo,  however,  to  which  the  author  de- 
sires to  call  especial  attention.  This  he  has  ventured  to  term  recurrent 
syphilitic  hudo. 

The  assertion  is  made  by  most  syphilographers  that  syphilitic  bubo, 
having  once  resolved,  does  not  return,  although  in  exceptional  cases  the 
affected  glands  may  remain  enlarged  for  a  considerable  time.  Tlie  author 
had  accepted  this  ipse  dixit  without  question  for  some  years,  attributing 
such  instances  of  bubo  as  appeared  in  late  syphilis  to  other  causes  than  the 
old  constitutional  taint.  In  most  cases  this  as.sumption  was  doubtless  cor- 
rect, but  in  some  of  them  it  probably  was  not.  The  following  are  cases  in 
point: — 

Case  1. — A  young  man,  24  years  of  age,  had  a  typic  chancre  followed,  by  a 
characteristic  course  of  secondary  syphilis.     Bubo  of  a  non-suppurative,  but  painful, 


.320  YEXEEEAL  ADEXITIS,  OE  BUBO. 

character  was  one  of  the  prominent  manifestations  of  the  disease.  Under  proper 
measures  of  treatment  improvement  was  quite  rapid.  Unfortunately,  however,  the 
patient  considered  himself  cured  at  the  end  of  about  six  months,  and  ceased  treatment. 
A  year  later  he  again  consulted  the  author  for  what  he  supposed  to  be  a  return  of 
the  disease  in  the  form  of  a  bubo  in  the  right  groin.  This  had  come  on  independently 
of  venereal  exposure,  and  examination  of  the  genitalia  failed  to  show  any  local 
cause  for  the  trouble.  In  appearance  and  feel  the  bubo  was  identic  with  the  ordi- 
nary primary  adenopathy  of  syphilis,  and  was  painless  except  on  very  firm  pressure. 
On  examining  the  mouth  several  small  mucous  patches  and  a  characteristically- 
fissured  tongue  were  found.  There  seemed  to  be  a  general  lowering  of  systemic  tone, 
and  loss  of  appetite  was  complained  of.  There  was  no  history  of  injury.  Under 
small  doses  of  mercury  and  potassic  iodid,  with  a  liberal  diet  and  tonics,  recovery 
was  complete  in  about  six  weeks. 

Case  2. — This  case  was  similar  to  the  above  excepting  in  the  fact  that  the  bubo 
was  attributed  by  the  patient  to  a  strain,  and  had  appeared  six  months  after  the 
disappearance  of  the  primary  bubo  and  three  months  after  any  possible  exposure. 
There  were  no  evidences  of  an  acute  inflammatory  process,  and  the  patient  was  in  fair 
systemic  condition.  The  usual  course  of  antisyphilitic  treatment,  combined  with 
counter-irritation,  caused  resolution  in  about  eight  weeks. 

Case  3. — This  case  was  that  of  a  young  woman  of  18:  a  cachectic,  debilitated 
subject,  who  had  been  affected  by  syphilis  about  a  year  and  a  half,  during  a  portion 
of  which  time  she  had  been  treated  very  thoroughly.  The  femoral  glands  were  in- 
volved originally,  and,  as  was  to  haA-e  been  expected,  if  the  author's  view  of  its  origin 
is  correct,  the  recurrent  disease  affected  the  same  glands.  Mucous  patches  were  pres- 
ent in  the  mouth,  but  the  genitalia  were  healthy.  jSTo  lesions  were  discoverable  in 
any  situation  which  would  account  for  the  bubo.  Suppuration  occurred  in  this  case, 
the  pus  being  scanty  and  thin,  and  the  glands  remained  indurated  for  some  time 
after  the  abscess-cavity  had  healed.  As  soon  as  the  patient  could  bear  antisyphilitic 
treatment,  however,  the  induration  rapidly  disappeared. 

Case  4. — A  medical  man,  35  years  of  age,  had  syphilis  two  years  before  the 
second  bubo  appeared.  At  the  time  of  its  appearance  he  was  a  little  out  of  health, 
but  had  experienced  nothing  that  might  account  for  the  glandular  enlargement.  He 
had  not  had  sexual  intercourse  for  four  weeks  prior  to  the  appearance  of  the  bubo, 
and  no  genital  lesions  had  been  detected  since  the  original  chancre.  Being  a  phy- 
sician, he  was  naturally  puzzled  by  the  occurrence  of  inguinal  bubo  without  any 
exciting  cause,  and  contrary  to  the  assertions  of  surgical  authorities.  The  bubo  finally 
suppurated,  and  did  not  heal  after  evacuation  until  a  thorough  course  of  anti- 
syphilitic treatment  was  instituted,  after  which  recovery  was  rapid. 

These  cases,  with  a  numher  of  others  observed  by  the  author,  seem  to 
show  that  many  cases  of  bubo,  in  which  the  causes  are  obscure,  are  due  to 
a  recurrence  of  glandular  syphilis.  That  this  is  unusual  is  explicable  by 
the  fact  that  it  only  recurs  in  certain  individuals.  In  strumous  persons,  for 
example,  there  is  an  inherent  tendency  to  glandular  enlargements,  and, 
whenever  in  the  course  of  syphilis  in  such  patients  there  'is  a  sudden  re- 
newal of  proliferative  energy  in  the  syphilitic  cells,  the  glands  are  affected 
because  of  their  affording  a  locus  minoris  resistentice.  The  same  process 
that  might  in  other  persons  produce  a  S3^philoderm  only  will  in  these  produce 
a  bubo.  The  recurrence  of  glandular  enlargement  in  the  groin  rather  than 
elsewhere  is  explicable  by  the  greater  susceptibility  of  these  glands  due  to 
their  situation,  which  exposes  them  to  local  irritation  and  invites  cell-de- 


DIAGNOSIS.  331 

posit^  and  to  the  fact  that  primary  adenopathy  is  most  marked  in  them, 
leaving  them  relatively  more  susceptible  than  the  general  glandular  system. 
Such  circumstances  as  alcoholism,  strain  in  lifting,  an  irritable  corn,  ex- 
posure to  cold,  or  trifling  genital  irritation,  may  act  as  exciting  causes  of 
recurrent  bubo  in  such  patients. 

Debility  and  cachexias  of  various  kinds  bear  the  same  relation  to  recur- 
rent syphilitic  bubo  as  does  struma. 

The  possibility  of  such  recurrent  adenopathies  constituting  some  of  the 
cases  of  so-called  huhon  d'emhlee  will  at  once  suggest  itself. 

Diagnosis. — Simple  Inflammatory  Bubo. — This  form  generally  results 
from  inflamed  chancroid,  but  may  be  due  to  gonorrhea,  balanitis,  herpes, 
inflamed  hard  chancre,  or  any  lesion  of  the  genitalia,  specific  or  simple.  It 
may  also  result  from  inflammation  of  any  tissue  the  absorbents  of  which 
empty  into  the  inguinal  or  femoral  glands.  Erysipelas  of  the  lower  extrem- 
ities has  been  known  to  cause  the  disease.  An  inflamed  corn  is  by  no  means 
a  rare  cause  of  inguinal  or  femoral  adenitis.  In  a  case  of  the  author's  at 
present  under  treatment  for  severe  gonorrheal  arthritis  of  the  knee,  well- 
marked  simple  bubo  exists  in  the  groin  of  the  affected  side.  When  simple 
bubo  suppurates,  it  presents  all  of  the  characters  of  simple  abscess.  The 
pus  in  these  cases  is  never  autoinoculable,  and  the  tissues  are  seldom 
attacked  by  phagedena.  Gangrene  may  occur,  but  very  rarely.  Healing  is 
generally  prompt  under  proper  measures  of  treatment. 

Virulent  Bubo. — This  form  is  invariably  the  result  of  chancroid  or 
mixed  sore,  and  often  becomes  phagedenic  or  gangrenous.  Suppuration  is 
an  invariable  result,  the  discharge  being  highly  corrosive  and  infectious, 
and  autoinoculable,  the  result  of  autoinoculation  being  typic  chancroid. 
Soon  after  its  evacuation  virulent  adenitis  assumes  the  physical  characteris- 
tics of  chancroid,  its  edges  being  sharply  cut  and  undermined  and  its  base 
eroded  and  sloughy.  Healing  is  slow  and  sinuses  and  fistulas  are  common 
results.  Even  before  it  is  opened  the  virulent  abscess  presents  certain  feat- 
ures which,  although  not  pathognomonic,  are  to  a  certain  extent  indicative 
of  the  character  of  the  lesion;  thus  the  pain  and  tenderness  are  marked,  the 
swelling  is  not  well  circumscribed,  the  integument  is  thinned  and  bluish, 
and  brawny  to  the  feel,  and  suppuration  is  quite  rapid  in  spite  of  all  meas- 
ures to  abort  the  inflammation. 

Syphilitic  Bubo. — This  form  follows  a  hard  chancre  or  a  mixed  sore, 
and  is  often  accompanied  by  general  adenopathy  by  the  time  the  case  is  pre- 
sented to  the  surgeon.  If  recurrent,  it  is  preceded  by  a  more  or  less  typic 
course  of  general  syphilis.  It  is  perfectly  circumscribed,  movable  upon  the 
sublying  tissues,  and  presents  a  peculiar  hard,  woody,  or  bone-like  feel  to 
the  touch.  It  is  slightly,  if  at  all,  tender,  and  is  altogether  of  a  passive 
nature.  Suppuration  is  rare,  and  when  it  does  occur  is  due  to  such  com- 
plicating circumstances  as  inflammation  of  the  primary  sore,  mixed  infec- 
tion, cachexia,  trauma,  struma,  or  tuberculosis,  and  the  pus  thus  produced 


322  VENEEEAL  ADENITIS^  OE  BUBO. 

is  never  autoinoculable  save  in  the  case  of  mixed  sore,  in  which  the  viru- 
lent element  imparted  by  the  chancroid  is  responsible  for  its  autoinocula- 
bility. 

Too  much  care  cannot  be  taken  to  ascertain  the  atrium  of  infection 
in  all  cases  of  bubo.  It  is  impossible  to  overestimate  the  importance  of 
this  in  cases  of  suspected  sj^philis.  A  careful  search  for  the  source  of  in- 
fection will  often  not  only  clear  up  a  doubtful  diagnosis,  but  in  extragenital 
sores  will  also  shed  much  light  on  the  manner  in  which  the  infection  was 
contracted. 

Teeatment. — The  systematic  management  •  of  venereal  adenitis  re- 
solves itself  into  several  practical  considerations,  viz.:  (1)  j)rophylaxis;  (3) 
prevention  of  suppuration;  (3)  extirpation  of  the  affected  glands;  (4)  treat- 
ment of  suppurating  adenitis;  (5)  treatment  of  sinuses  and  exposed  lym- 
phatic glands;  (6)  treatment  of  gangrenous  and  phagedenic  adenitis;  (7) 
treatment  of  chronic  or  indolent  bubo;  (8)  treatment  of  syphilitic  glandu- 
lar enlargement,  primary  or  recurrent,  and  of  other  forms  when  complicated 
by  syphilis. 

With  the  exception  of  the  prevention  of  suppuration  and  the  treatment 
of  gangrenous  and  phagedenic  adenitis,  these  headings  apply  equally  to  both 
the  simple  and  virulent  forms  of  the  disease.  The  formation  of  pus  cannot 
be  prevented  in  virulent  gland  infection,  and  the  simple  form  is  not  very 
liable  to  either  gangrene  or  phagedena,  although  either  may  occur  under 
certain  conditions. 

The  liability  to  the  occurrence  of  venereal  adenitis  is,  of  course,  greatly 
enhanced  by  any  virulent  property  that  may  exist  in  the  genital  lesion,  and 
is  of  necessity,  therefore,  much  greater  in  chancroid  than  in  gonorrhea, 
balanitis,  or  any  of  the  simpler  forms  of  local  irritation  that  frequently 
cause  adenitis.  Prophylaxis  is  consequently  much  less  likely  to  prove 
efEeetive  in  chancroid,  and  especially  in  its  virulent  form.  Whatever  the 
source  of  irritation,  the  chief  prophylactic  measure  is  rest,  though  in  most 
cases  of  gonorrhea  or  balanitic  lesions  and  even  in  chancroid,  unless  large  and 
destructive,  this  is  not  practicable.  The  patient  may  at  least  be  impressed 
with  the  importance  of  avoiding  strains  and  violent  efforts  so  far  as  possible. 
When  the  patient  is  compelled  to  go  about,  and  especially  if  his  occupation 
involves  muscular  effort  or  prolonged  standing  at  the  desk  or  counter,  an 
excellent  plan  is  to  apply  a  double  spica  bandage  with  a  compress  in  each 
groin  on  the  first  indication  of  inguinal  irritation. 

An  important  indication  is  to  maintain  free  action  of  the  bowels; 
straining  at  stool  tends  to  produce  inguinal  irritation.  Patients  with  bubo 
generally  complain  of  pain  in  the  groin  during  a  difficult  stool.  The  most 
important  prophylactic  measure  is  proper  treatment  of  the  genital  or  ure- 
thral lesion  from  which  infection  of  the  glands  is  feared.  The  sooner  irri- 
tation and  inflammation  are  allayed  and  infection  destroyed,  the  sooner  the 
danger  of  adenitis  will  disappear.    In  chancroid  the  danger  of  gland  infec- 


TEEATMENT    OF    VENEREAL   ADENITIS,    OR   BUBO.  333 

tion  is  inversely  to  the  rapidity  with  which  the  virulency  of  the  local  sore  is 
corrected.  Thorough  cauterization  of  the  chancroid  is  therefore  the  best 
means  of  prophylaxis. 

In  the  event  that,  in  spite  of  prophylaxis,  adenitis  develops,  strenuous 
endeavors  should  always  be  made  to  prevent  the  formation  of  pus,  for 
healing  after  incision  or  rupture  often  requires  considerable  time,  aside 
from  the  danger  of  inflammatory  or  hemorrhagic  complications.  A  very 
unsightly,  discolored  cicatrix  is  also  left — a  very  important  consideration, 
especially  in  women.  One  of  the  best  local  measures  of  pus  prophylaxis 
is  absolute  rest,  combined  with  applications  of  ichthyol  solution  in  a 
strength  of  from  25  to  50  per  cent.  A  very  useful  combination  is  the  fol- 
lowing:—  ■   . 

U  Ichthyol 3ij. 

Tr.  belladon 3ij. 

Hydrarg.  bichlor gr.  v. 

Aq.  dest q.  s.  ad  5j- 

M.     Sig. :    Apply  t.  d.  with  camel's-hair  brush. 

Counter-irritation,  either  with  or  without  pressure,  has  been  extensively 
employed.  The  counter-irritant  most  frequently  used  is  ordinary  tincture 
of  iodin;  the  compound  tincture  with  an  extra  amoimt  of  iodin  added  is 
better.  A  shot-bag  of  about  five  pounds'  weight  is  an  excellent  means  for 
the  application  of  pressure.  A  better  plan,  however,  is  to  apply  a  spica 
bandage  over  compressed  sponge,  laid  upon  the  bubo,  the  sponge  being  sub- 
sequently kept  wet  with  cold  water.  As  the  sponge  swells,  a  very  firm  and 
equable  pressure  is  exerted  upon  the  tumor,  in  addition  to  the  antiphlogistic 
effects  of  cold.  The  benefits  derived  from  this  form  of  treatment  are  ex- 
plained by  the  local  anemia  thus  produced  and  the  prevention  of  further 
exudate. 

Instead  of  pressure,  hot  poultices  may  advantageously  be  used  con- 
jointly with  ichthyol.  The  application  of  leeches  has  been  recommended  to 
avert  suppuration  by  causing  local  depletion,  but  the  leech-bites  form  lesions 
that  may  become  infected  by  autoinoculation  in  case  the  bubo  should  prove 
to  be  virulent,  and  the  fewer  such  lesions  the  better. 

The  injection  of  carbolic  acid  into  the  substance  of  the  inflamed  gland 
has  been  strongly  recommended.  The  author's  experience  with  this  method 
has  not  been  encouraging.  It  could  hardly  have  any  effect  in  virulent  bubo, 
and  its  antisuppurative  power,  even  in  simple  inflammation,  is,  to  say  the 
least,  doubtful.  The  mode  of  procedure  is  to  make  a  number  of  injections 
of  a  1  to  15  solution  of  carbolic  acid  into  the  substance  of  the  inflamed 
gland.  The  author  has  used  the  bichlorid  of  mercury  in  this  manner  with 
some  success.  In  obstinate  syphilitic  bubo  the  bichlorid  or  calomel  may  be 
used  with  the  view  of  hastening  resolution. 

Lead-iodid  ointment,  in  combination  with  the  extract  of  belladonna, 
is  sometimes  successful  in  aborting  simple  bubo.     Acetate  of  lead  is  rec- 


324  VENEEEAL   ADENITIS,    OK   BUBO. 

ommended  by  Ziessl.  His  method  is  to  soak  a  number  of  compresses 
in  lead  solution  and  bind  them  upon  the  bubo,  keeping  them  thoroughly 
wet.  The  ordinary  lead-and-opium  wash,  with  an  increased  proportion  of 
both  ingredients,  is  much  better  than  a  simple  solution  of  lead  acetate. 

The  most  effective  antisuppurative  measure  at  our  command  is  the 
much-used  and  little-understood  poultice. 

There  occurs  in  all  inflammations  profound  circulatory  disturbance, 
and  at  the  period  of  purulent  formation  this  chiefly  consists  in  obstruction 
and  stasis,  enhanced  by  the  circumscribed  collection  of  cells  to  a  degree 
proportionate  to  the  tension  present.  As  a  result  of  the- pressure,  there  is 
lymphatic  obstruction  and  consequent  inhibition  of  the  function  of  the  ab- 
sorbents. The  vitality  of  the  tissue-elements  is  impaired  to  an  extent 
greatly  modified  by  the  amount  of  pressure  and  circulatory  disturbance,  this 
impairment  of  nutrition  being  greatest  in  the  tissues  immediately  contigu- 
ous to  the  pus  and  shading  off  into  the  surrounding  tissues.  As  a  result 
mainly  of  the  pressure  of  the  purulent  formation,  a  layer  of  partially-or- 
ganized lymph  forms  in  the  abscess,  which  in  chronic  abscess  forms  a 
pseudomembrane,  erroneously  termed  the  pyogenic  membrane. 

In  acute  abscess,  however,  it  simply  shades  off  into  the  surrounding 
tissues,  which  are,  in  a  measure,  matted  together  by  exudate.  The  thickness 
and  degree  of  organization  of  the  layer  of  lymph,  and  the  extent  to  which 
the  vitality  of  the  surrounding  tissues  is  impaired  (which,  as  already  stated, 
depends  mainly  upon  the  amount  of  inflammatory  exudate  and  consequent 
circulatory  disturbance)  determines  the  facility  with  which  resolution  of 
circumscribed  inflammation,  on  the  one  hand,  and  formation  of  pus,  upon 
the  other,  take  place.  It  was  formerly  believed  that  pus,  once  formed  in  a 
circumscribed  collection,  cannot  be  absorbed,  but  this  is  erroneous. 

It  is  well  known  that  the  first  factor  in  the  production  of  the  phe- 
nomena of  inflammation  is  irritation,  and  that  this  results  in  the  various 
changes  just  described.  Irritation  is  enhanced  by  the  accumulation  of  in- 
flammatory products.  "\^nien  a  hot  poultice  is  applied  to  inflamed  tissues, 
the  irritation  and  pain  are  primarily  relieved,  and  this  has  an  immediate 
effect  in  preventing  or  lessening  further  exudation,  and  probably  induces 
also  a  certain  amount  of  vascular  contraction,  via  the  vasomotor  nerves.  In 
lessening  exudate  circulatory  obstruction  is  diminished,  thus  relieving  the 
impairment  of  nutrition  resulting  both  from  pressure  and  stasis.  Eelief  of 
pressure  is  attended  by  restoration  of  function  in  the  absorbents,  which  is 
necessary  for  resolution. 

If  inflammation  is  severe,  with  extensive  exudation,  the  nutrition  of  a 
certain  number  of  embryonal  tissue-elements  becomes  so  disturbed  that  reso- 
lution, which  readily  occurs  when  the  vitality  of  the  tissues  is  only  mod- 
erately impaired,  cannot  occur.  Here,  moist  heat  will  fail  to  prevent  sup- 
puration, but  will  limit  exudate,  and  prevent  further  tissue-change.  There 
is  an  indurated  area  about  an  abscess,  as  is  well  known,  in  which  the  changes 


TREATMENT   OF   VENEREAL    ADENITIS,    OR   BUBO.  325 

described  occur.  The  cells  in  the  periphery  of  this  area  may  have  sufficient 
vitality  to  become  resolved,  while  the  changes  in  those  in  immediate  rela- 
tion to  the  abscess-cavity  have  gone  too  far  to  permit  of  resolution.  It  is 
an  easily  verified  clinical  fact  that  the  less  the  degree  of  induration  sur- 
rounding an  abscess,  and  the  sooner  it  resolves  or  breaks  down  into  pus,  the 
sooner  will  the  abscess  heal  after  incision.  There  is  much  of  truth  in  the 
popular  idea  that  an  abscess  should  be  "ripe"  before  it  is  opened;  healthy 
granulations  cannot  arise  from  tissues  devitalized  by  the  pressure  of  a  large 
amount  of  inflammatory  exudate.  The  distinctness  of  fluctuation,  which  is 
so  evidently  increased  by  poulticing,  depends  upon  the  amount  of  surround- 
ing exudate,  and  while  the  tissue  over  an  abscess  is  becoming  thinned  by  the 
pressure  of  the  pus,  the  inflammatory  exudate  in  its  meshes  is  being  removed 
by  the  action  of  the  poultices. 

The  action  of  moist  heat,  then,  may  be  formulated  as  follows:  1.  It 
will  prevent  pus-formation  if  the  vitality  of  the  tissue-elements  has  not  be- 
come too  greatly  impaired.  2.  It  will  hasten  maturation,  and  limit  the 
purulent  formation,  if  the  impairment  of  nutrition  has  gone  too  far  to  per- 
mit of  resolution.  3.  It  will  diminish  the  indurated  area  about  an  abscess 
after  incision  or  spontaneous  rupture,  and  favor  healthy  granulation. 

It  may  be  accepted,  therefore,  that  the  application  of  moist  heat  is 
beneficial  at  any  stage  of  acute  inflammation  and  abscess.  Such  applica- 
tions, it  is  true,  may  be  continued  too  long,  making  the  tissues  boggy  and 
infiltrated,  but  this  can  be  avoided.  In  speaking  of  the  action  of  poultices, 
it  is  assumed  that  they  are  properly  used.  They  are  not,  as  a  rule,  properly 
made,  and,  if  hot  at  the  outset,  are  allowed  to  become  cool  before  they  are 
applied.  If  applied  hot,  they  are  usually  allowed  to  become  cold,  thus 
neutralizing  any  beneficial  effects  of  the  heat,  if,  indeed,  the  inflammation 
has  not  been  augmented  by  clumsy  manipulation  and  rapid  changes  of  tem- 
perature. A  poultice  should  be  renewed  sufficiently  often  to  keep  it  hot, 
or  no  benefit  can  be  expected.  A  convenient  method  of  obviating  the  neces- 
sity of  making  a  fresh  poultice  for  each  application,  is  to  prepare  a  number, 
and  keep  them  hot  by  means  of  the  ordinary  bread-steamer.  If,  after  a 
bubo  has  been  opened,  antiseptic  poultices  are  necessary,  equal  parts  of  char- 
coal and  linseedmeal,  mixed  with  hot  yeast  instead  of  water,  form  the  best 
material. 

A  valuable  antisuppurative  measure  is  the  internal  administration  of 
calx  sulpJiurata,  or,  as  it  has  been  erroneously  termed,  sulphid  of  calcium. 
Pure  sulphid  of  calcium  is  not  found  in  the  drug-market,  nor  has  it  ever 
been  used  therapeutically.  Calx  sulpliurata,  or  sulphurated  lime,  as  de- 
scribed by  the  new  pharmacopeia,  is  a  mixture  of  sulphate  and  sulphid  of 
calcium  in  varying  proportions,  containing  not  less  than  36  per  cent,  of  the 
latter.     This  drug  has  been  highly  lauded  as  an  antisuppurative,  and  has 


^  Piffard,  especially,  has  indorsed  calx  nulphurata  in  gland  infections. 


326  TEXEEEAL  ADEXITIS,  OE  BUBO. 

been  especially  recommended  in  the  treatment  of  venereal  adenitis.^  The 
author  believes  from  considerable  experience  in  its  nse  that  it  is  a  remedy 
of  great  value,  and  that  it  has  several  effects,  varying  with  the  character  of 
the  inflammation.  Its  action  in  the  prevention  of  suppuration  is  similar  to 
that  of  poultices,  and  like  the  latter,  unless  the  inflammatory  changes  have 
gone  too  far  to  permit  of  resolution,  it  will  favor  supjjuration  and  hasten 
maturation.  It  probably  acts  by  producing  fatty  degeneration  of  the  in- 
flammatory exudate,  thus  relieving  the  circulation.  Unlike  poudtices,  it  will 
cause  pus  that  is  already  fully  formed  in  a  circumscribed  cavity  to  become  ab- 
sorbed, probabl}^  through  this  same  fatty  degeneration.  The  possibility  of 
this  has  been  denied,  but  numerous  instances  of  such  absorption  are  met 
with.     A  case  observed  by  the  author  is  especially  striking: — 

Case. — A  pale,  lymphatic-  female  entered  the  hospital,  suffering  from  a  slight 
gonorrheal  vaginitis,  and  presenting  in  the  left  groin  a  suppurating  bubo  of  a 
peculiarly  chronic  character,  there  being  distinct  fluctuation  throughout  and  no 
redness  or  induration.  The  tumor  was  as  large  as  a  good-sized  hen's  egg,  and  the 
skin  covering  it  was  so  thin  that  it  was  expected  to  burst  spontaneously  at  any 
moment  after  her  admission.  The  woman  was  so  anxious  to  avoid  a  scar  that  she 
was  experimentally  given  V2-giain  doses  of  calx  svIpJiurata  every  three  hours,  and 
operation  deferred.     The  pus  entirely  absorbed  in  less  than  a  week. 

The  dose  of  the  drug  should  vary  Avith  the  stage  of  the  inflamma- 
tion. As  a  preventive  of  suppuration,  ^/^g  grain  should  be  given  every 
hour.  When  inflammation  has  so  far  advanced  that  suppuration  is  in- 
evitable, the  dose  should  be  increased  to  from  ^/^  to  ^/o  grain  every  three 
hours.  In  chronic  and  indolent  bubo,  and  in  cases  in  which  unhealthily 
secreting  surfaces  or  sinuses  are  left  after  incision  or  rupture  of  the  abscess, 
large  doses  will  often  speedily  bring  about  healthy  action,  the  surrounding 
induration  rapidly  disappearing  and  the  character  of  the  pus  changing  from 
sanious  or  ichorous  to  a  free  secretion,  after  which  granulation  is  quite 
rapid' 

The  prevailing  variance  of  opinion  as  to  the  effect  of  calx  sulphurata 
in  inflammation  is  only  explicable  by  the  ignorance  that  prevails  in  respect 
to  its  proper  use.  Like  moist  heat,  this  drug,  in  proper  doses,  may  produce 
beneficial  effects  at  any  stage  or  in  any  variety  of  glandular  inflammation. 

Notwithstanding  what  has  been  said  of  the  antisupj)urative  treatment 
of  bubo,  we  are  compelled  to  acknowledge  that  it  is  only  effective  in  simple 
adenitis,  and  that  the  virulent  form  must  inevitably  suppurate;  but  as  our 
antisu]3purative  measures  may,  under  certain  circumstances,  also  promote 
maturation,  and  will  always  limit  the  surrounding  inflammation,  they  are 
always  indicated.  Again,  it  is  not  usually  possible  to  affirm  that  a  bubo  is 
virulent  prior  to  suppuration.  •  If,  however,  the  primary  lesion  be  an  auto- 
inoculable  chancroid,  and  the  resulting  adenitis  runs  a  very  acute  course,  we 
are  warranted  in  assuming  that  it  is  virulent.  After  the  bubo  is  opened  the 
diagnosis  is,  of  course,  quite  easy. 


TREATMEXT  OF  VENEREAL  ADEXITIS,  OR  BrBO.  327 

The  importance  of  internal  measures  in  the  management  of  bubo  can 
Scarcely  be  overrated  and  may  properly  be  alluded  to  in  connection  with  the 
antisuppurative  treatment  of  the  disease.  As  soon  as  bubo  threatens  free 
catharsis  is  indicated;  throughout  the  course  of  the  affection  mild  laxatives 
should  be  given,  for  reasons  stated  in  connection  with  prophylaxis.  If  the 
patient  be  debilitated,  tonics  should  be  freely  given,  and,  if  struma  be  evi- 
dent, codliver-oil  and  the  syr.  ferri  iod.  should  be  administered.  .  As  a  rule, 
too  much  dependence  is  placed  upon  local  measures  and  too  little  attention 
given  to  the  constitutional  condition. 

Chronic,  indurated,  open  bubo  not  infrequently  heals  promptly  under 
jiroper  constitutional  treatment.  There  is  one  point  with  reference  to 
prophylaxis  of  suppuration  in  bubo  which  it  may  be  well  to  mention.  Many 
patients  object  to  measures  designed  to  "scatter"  the  bubo,  on  the  ground 
that  such  a  plan  "drives  the  poison  into  the  blood."  If  the  treatment  suc- 
ceeds in  aborting  the  bubo,  all  subsequent  skin  eruptions  and  perhaps  other 
troubles  will  be  charged  to  it.  The  objections  of  such  ignorant  persons  are 
mainly  to  such  measures  as  they  understand  to  be  antisuppurative,  such  as 
counter-irritation  and  pressure.  There  might  be  some  foundation  for  this 
popular  notion  if  it  were  possible  to  discuss  a  virulent  bubo.  When  we 
meet  with  a  patient  of  this  kind,  however,  we  should  do  our  utmost  to  pro- 
mote suppuration,  hoping  that  the  resulting  scar  will  be  sufficiently  large 
and  unsightly  to  give  satisfaction. 

When,  despite  treatment,  bubo  progresses,  there  is,  in  the  author's 
opinion,  but  one  course  to  pursue,  viz.:  extirpation  of  the  infected  glands. 
It  is  not  wise  to  delay  operation  after  the  glands  have  attained  even  moder- 
ate size  and  the  inflammation  shows  a  tendency  to  increase.  As  already 
stated,  small  disseminated  abscesses  appear  in  the  gland  early,  and  may  at 
any  time  rupture,  with  consequent  periglandular  infection.  Once  this  has 
occurred  the  time  is  past  in  which  to  make  a  clean  and  successful  radical 
operation.  Extirpation  of  the  glands  shortens  the  course  of  the  disease  and 
the  resulting  scar  is  usually  trifling  as  compared  with  the  unsightly  one 
that  ordinarily  follows  suppurating  bubo.     Primary  union  is  the  rule. 

When  operation  is  refused  or  inexpedient,  and  suppuration  seems  in- 
evitable, the  formation  of  pus  should  be  favored.  If  poultices  have  not  al- 
ready been  employed,  they  should  at  once  be  applied.  If  calx  sulphurata 
in  small  doses  has  already  been  used,  the  dose  should  be  increased  to  2  grains 
every  three  hours.  As  soon  as  fluctuation  is  distinct  the  abscess  should  be 
opened.  An  early  opening  is  especially  indicated  in  virulent  bubo,  as  bur- 
rowing is  likely  to  occur. 

The  manner  of  opening  a  suppurating  bubo  is  important.  As  a  rule, 
the  operation  is  only  half-done,  a  small  incision  being  made,  barely  suffi- 
cient to  give  exit  to  the  pus  and  entirely  inadequate  to  permit  proper  cleans- 
ing of  the  abscess-cavity.  If  the  process  be  virulent,  troublesome  and  ex- 
tensive burrowing  may  occur.    The  only  way  to  prevent  this  is  to  lay  open 


> 

328  VENEREAL  ADENITIS,  OR  BUBO. 

all  sinuses  and  pockets  tliorouglily.  The  abscess-cavit}'  should  be  washed 
out  with  some  antiseptic,  and,  if  at  all  virulent  in  appearances,  pure  carbolic 
acid  should  be  thoroughly  applied  by  means  of  a  swab,  and  carried  to  the 
bottom  of  all  sinuses  and  depressions.  The  edges  should  now  be  thoroughly 
cut  awa}',  if  undermined,  and  the  cavity  converted  into  the  shape  of  a 
saucer,  as  nearly  as  possible.  The  cut  surfaces  will  require  the  application 
of  pure  carbolic  acid  to  prevent  infection.  The  peroxide  of  hydrogen,  or, 
better,  pyrozone,  which  has  come  into  great  favor  as  an  antiseptic,  is  useful 
in  both  virulent  bubo  and  chancroid,  apparently  destrojdng  their  specific 
properties  and  setting  up  healthy  action.  It  may,  therefore,  oftentimes  an- 
swer in  lieu  of  cauterization  with  more  powerful  irritants  or  detergent  and 
antiseptic  substances.  The  abscess-cavity  should  finally  be  dusted  with 
iodoform  and  packed  with  gauze. 

TVhen  a  suppurating  bubo  is  simple,  as  may  usually  be  determined  by 
the  character  of  the  pus,  the  histor}-,  and  course  of  the  inflammation,  cau- 
terization is  unnecessary.  If  there  be  much  surrounding  induration,  or  if 
the  flow  of  pus  after  incision  should  be  scanty,  poultices  should  be  applied. 
All  involved  glands  should  be  extirpated.  Within  a  few  days,  after  the 
bubo  has  taken  on  healthy  action,  it  may  require  gentle  stimulation. 
Peruvian  balsam  applied  on  gauze  meets  this  indication.  The  author's 
preference  is  for  the  following  formula,  rather  than  the  clear  balsam: — 
IJ  lodoformi 3ij. 

Ac.  borici 3j. 

Bals.  Peruviani §j. 

Vaselinse    q.  s.  ad  gij. 

M.     Sig. :    Apply  on  gauze. 

When  a  more  stimulating  application  is  required,  the  following  is-  use- 
ful:— 

li.  Argenti  nitratis gr.  xx. 

Pulv.  stramonii  fol , 3j. 

Ext.  belladonnse gr-  x. 

Cerati  simplieis 5ij- 

M.     Sig.:    Apply  on  gauze. 

The  solid  stick  of  silver  nitrate  may  be  required  from  time  to  time,  as 
in  ordinary  granulation.  When  a  bubo  is  sluggish  and  secreting  unhealth- 
ily, a  powder  of  equal  parts  of  oxid  of  zinc  and  red  cinchona-bark  often  acts 
well.  The  advantages  of  removing  the  edges  of  the  bubo  after  incision  and 
converting  it  into  a  saucer-shaped  cavity  are  several.  It  summarily  disposes 
of  the  edges, — which  so  frequently  tend  to  invert  and  almost  invariably  be- 
come indurated  and  thickened,  thus  preventing  healing, — favoring  cleanli- 
ness, and  permitting  applications  to  all  parts  of  the  cavity.  It  also  prevents 
burrowing,  facilitates  the  removal  of  projecting  glands,  and  imparts  to 
the  bubo  many  of  the  characters  of  simple  ulcer.  Finally,  it  favors  rapid 
healing  from  the  edges  as  well  as  from  the  bottom,  and  leaves  a  much  less 


TEEATMENT    OF   YENEEEAL   ADENITIS,    OE    BrBO.  329 

puckered  and  discolored  scar  than  when  the  edges  are  left.  Eegarding  the 
various  methods  of  evacuating  a  suppurating  bubo  without  free  incision, 
such  as  multiple  puncture,  aspiration,  and  Auspitz's  method  of  breaking 
up  the  inflamed  gland  by  means  of  a  blunt  probe  introduced  through  a  small 
incision,  they  must  sooner  or  later  be  followed  by  free  incision  if  the  bubo 
be  virulent,  with  the  probable  result  of  finding  that  burrowing  to  a  greater 
or  less  extent  has  occurred.  It  is,  of  course,  desirable  to  avoid  a  scar  if  pos- 
sible, and  in  simple  bubo  this  may  sometimes  be  done,  especially  by  aspira- 
tion and  the  use  of  calx  sulphurata;  but,  as  a  rule,  the  plan  that  has  been 
suggested  will  be  found  to  yield  the  best  results. 

The  management  of  sinuses  and  exposed  glands  demands  some  atten- 
tion. If  a  bubo  be  properly  opened,  and  the  undermined  and  degenerated 
tissue  at  its  edges  thoroughly  removed,  sinuses  are  not  apt  to  form,  but  in 
neglected  or  improperly-treated  cases  sinuses  often  result.  When  prac- 
ticable, each  sinus  should  be  thoroughly  laid  open,  the  indurated  track  cut 
away,  and  the  wound  sutured.  They  may  sometimes  be  induced  to  heal  by 
stimulating  applications,  but  they  are  quite  liable  to  reopen,  especially  if 
the  patient  is  cachectic  or  moves  about  a  great  deal,  the  tissue  about  them 
being  of  very  feeble  vitality.  When  too  deep  to  be  freely  laid  open,  or  when 
in  dangerous  proximity  to  important  structures,  they  may  often  be  induced 
to  granulate  from  the  bottom  by  keeping  them  freely  open  with  sponge- 
tents,  curettement,  and  stimulation  with  caustics.  An  excellent  plan  for 
deep  sinuses  is  that  often  used  for  sinuses  and  fistulas  in  other  situations, 
viz.:  incision  of  the  external  opening  and  the  insertion  of  a  wedge-shaped 
piece  of  wax,  the  base  of  which  is  gradually  shaved  off  as  the  bottom  of  the 
cavity  granulates.  Injections  of  very  hot  water,  frequently  repeated,  com- 
bined with  the  use  of  pencils  or  tents  of  iodoform,  sometimes  give  excellent 
results.  The  tents  are  to  be  dipped  in  vaselin  and  inserted  into  the  sinuses, 
care  being  taken  that  the  bottom  is  reached.  They  are  then  cut  off  level  with 
the  surface  and  powered  iodoform  and  a  compress  applied  over  all.  Injec- 
tions of  iodoform  and  glycerin,  5ij  to  the  ounce,  often  act  well.  Injections 
of  pure  iodin  often  succeed  when  all  other  means  fail. 

Chronic  and  indolent  adenitis,  with  or  without  suppuration,  is  usually 
met  with  in  strumous,  debilitated  or  cachectic  subjects.  In  such  cases,  the 
bubo  may  run  an  ordinary  acute  or  subacute  course,  but  after  evacuation 
of  the  pus  it  becomes  a  chronic,  indolent  ulcer.  The  phagedenic  variety  is 
especially  apt  to  become  chronic  and  last  indefinitely. 

The  chief  measures  of  treatment  for  chronic  bubo  in  scrofulous  or 
cachectic  subjects  consist  in  the  administration  of  such  remedies  as  iodid 
of  iron,  codliver-oil,  arsenic,  iodoform,  quinia,  and  the  mineral  acids.  A 
liberal  diet,  of  which  milk  and  cream  should  form  the  principal  ingredients, 
and  improved  hygiene  are  usually  called  for.  It  is  in  such  cases  that  the 
sulphurated  lime  will  yield  the  best  results.  Maximum  doses  should  be 
given.    As  illustrated  by  a  case  already  cited,  even  absorption  of  pus  may  be 


330  VENEEEAL    ADENITIS,    OK    BUBO. 

induced  by  this  drug.  If  the  bubo  suppurates  in  these  chronic  cases,  aspira- 
tion may  be  used  in  conjunction  with  the  sulphurated  lime  where  it  is  espe- 
cially desirable  to  avoid  a  scar. 

Chronic  bubo  may  remain  hard  and  indolent  for  a  long  time  before  pus 
forms,  and  various  local  measures  have  been  recommended  for  inducing 
resolution  without  suppuration.  Ko  method  is  to  be  considered  where  the 
bubo  is  troublesome  save  extirpation,  unless,  as  already  indicated,  it  is  so 
desirable  to  avoid  a  scar  that  measiires  of  temporizing  are  warrantable. 
Here  counter-irritation  and  pressure  may  be  tried.  All  measures  of  treat- 
ment are  apt  to  fail  in  bringing  about  resolution  in  chronic  adenitis.  Sup- 
puration, if  it  occurs  at  all,  is  apt  to  be  long  delayed,  and  much  time  may 
be  lost  while  waiting  for  the  bubo  to  maturate.  Complete  extirpation  of 
the  enlarged  glands  constitutes  a  radical  cure.  The  operation  should  be 
performed  as  in  cases  of  tumor,  with  full  antiseptic  precautions.  The  cav- 
ity left  after  removal  of  all  the  diseased  tissues  should  be  deeply  sutured 
and  perfectly  closed.  Union  by  first  intention  is  the  rule.  This  is  a  highly 
satisfactory  method  of  dealing  with  a  very  annoying  and  obstinate  affection. 
Union  is  often  perfect  even  where  more  or  less  pus  is  present  in  the  glands. 

The  form  of  bubo  associated  with  the  genital  lesion  erroneously  de- 
scribed as  "lupoid  of  the  vulva"  is  apt  to  be  very  troublesome,  and  it  is 
doubtful  whether  severe  cases  of  this  kind  are  ever  cured.  When  this  form 
of  bubo  refuses  to  yield  to  the  ordinary  local  treatment  associated  with 
tonics  and  dietetics,  the  occasional  application  of  the  actual  cautery  may 
excite  healthy  action,  active  granulation,  and  repair.  As  a  dressing,  pow- 
dered charcoal  is  probably  best.  An  infusion  of  cinchona-bark  may  also  be 
of  service,  a  piece  of  lint  being  saturated  with  it  and  laid  upon  the  part, 
to  be  subsequently  wet  often  enough  to  keep  it  moist.  Bumstead  recom- 
mends the  pure  persulphate  of  iron.  In  the  author's  experience  the  man- 
agement of  these  cases  is  anything  but  satisfactory. 

The  management  of  exposed  and  hyperplastic  glands  is  sufficiently 
simple.  When  free  glands  are  found  on  opening  a  bubo,  they  should  at  once 
be  removed,  for  if  left  they  act  as  foreign  bodies  and  are  constant  sources 
of  infection,  prolonging  the  healing  process  indefinitely.  In  many  cases  the 
fingers  will  suffice  for  their  removal;  Volkmann's  spoon  or  Piffard's  curette 
may  be  used.  Where  practicable,  all  of  the  diseased  area  should  be  dis- 
sected out  and  an  attempt  made  to  secure  primary  union,  as  may  be  done 
in  many  chronic  cases  and  in  acute  cases  before  periadenitis  has  developed. 

A  very  important  point  in  the  treatment  of  open  bubo  is  the  question 
of  constitutional  syphilis.  If  a  genital  sore  be  of  the  mixed  variety,  the 
resulting  bubo  is  likely  to  heal  very  slowly,  if  at  all,  until  mercury  is  ad- 
ministered. Where  the  patient  has  had  syphilis  a  certain  length  of  time 
prior  to  the  occurrence  of  the  adenitis,  he  will  require  a  full  mercurial 
course.  If  the  syphilis  be  somewhat  remote,  or  the  patient  debilitated  and 
suffering  from  the  syphilitic  cachexia,  a  course  of  mixed  antisyphilitic  treat- 


TEEATilEXT    OF    TEXEKEAL    ADEXITIS^    OR   BUBO.  331 

ment,  on  the  one  hand,  or  of  small  tonic  closes  of  mercury,  upon  the  other, 
will  be  required.  The  necessity  for  antisyphilitic  remedies  in  instances  of 
glandular  mixed  infection  and  suppuration  following  syphilitic  adenopathy 
is  obvious.  In  cases  of  syphilitic  cachexia  the  administration  of  small  tonic 
doses  of  the  bichlorid  of  mercury  will  often  rapidly  induce  healing  in  a  bubo 
that  has  run  a  very  prolonged  course,  the  general  health  of  the  patient 
meanwhile  improving  in  a  marked  degree.  This  tonic  action  of  mercury  is 
not  generally  appreciated,  even  by  those  who  employ  it  extensively. 

Eecurrent  syphilitic  bubo  requires  the  ordinary  treatment  of  syphilis 
in  combination  with  tonics. 

The  treatment  of  venereal  adenitis  complicated  by  gangrene  or  phage- 
dena does  not  differ  from  that  of  chancroid  attended  by  the  same  complica- 
tions. Much  may  be  done  to  prevent  these  disagreeable  and  serious  com- 
plications by  attention  to  the  constitutional  condition.  If  cachectic  or  de- 
bilitated the  patient  should  at  once  be  put  upon  tonics  and  a  highly-nour- 
ishing diet.  There  is  no  better  tonic,  under  such  circumstances,  than  the 
potassio-tartrate  of  iron:  a  remedy  highly  extolled  by  Eieord  in  phagedena. 
It  is  to  be  remembered,  however,  that  we  occasionally  meet  with  cases  in 
which  phagedena  occurs  without  evident  cause,  an  innate  predisposition  to 
the  affection  apparently  existing. 

When  phagedena  or  gangrene  attacks  a  bubo,  the  first  indication  is 
thorough  destruction  of  the  diseased  surfaces  by  cauterization.  This  should 
not  be  done  in  a  feeble,  half-way  manner,  or  it  will  be  ineffectual,  perhaps 
injurious,  and  will  require  repetition.  An  anesthetic  should  always  be  given 
or  cocain  used  if  the  diseased  surface  is  extensive,  or  the  work  may  not  be 
thoroughly  done.  All  projecting  glands  should  be  first  removed  by  the 
curette.  The  caustic  used  is  not  of  paramount  importance  provided  it  be 
sufficiently  powerful  to  destroy  the  tissues  for  the  required  extent.  The 
Paquelin  thermocautery,  pure  bromin,  or  Eicord's  paste  may  be  used,  the 
author's  preference  being  bromin.  After  the  cauterization  an  antiseptic 
poultice  should  be  applied  and  morphin  freely  given  to  alleviate  the  severe 
pain  that  is  sometimes  experienced.  AYhen  the  carbo-sulphuric  paste  is  used 
the  patient  should  be  kept  well  under  the  influence  of  opium  during  its 
application.  Opium  has  been  said  to  have  a  specific  action  in  checking 
phagedena,  independently  of  its  narcotic  property.  As  has  been  stated  in 
connection  with  the  subject  of  phagedenic  chancroid,  Eieord  had  great  faith 
in  opium  in  such  cases. 

When  cauterization  is  impracticable,  iodoform,  carbolic  acid,  peroxid 
of  hydrogen,  iodin,  and  the  potassio-tartrate  of  iron  in  a  strength  of  from 
gr.  XX  to  gr.  xl  to  the  ounce  of  water  have  each  their  advocates.  The  author 
prefers  the  peroxid  of  hydrogen,  followed  by  close  packing  of  the  cavity 
with  a  mixture  of  finely-powdered  iodoform  and  charcoal. 


PART  V. 

SYPHILIS. 


CHAPTEE  XIV. 

Syphilis. 

histoet  and  geneeal  chaeacteeistics;   incubation  and 
initiatoet  peeiods  of  syphilis. 

Syphilis  is  by  far  the  most  important  as  well  as  the  most  interesting 
of  the  venereal  diseases.  There  is  no  disease  that  has  been  more  wide-spread 
in  its  dissemination  or  more  potent  in  its  influence  upon  the  human  species. 
iSTo  class  of  individuals^  no  stratum  of  society,  has  remained  free  from  more 
or  less  general  contamination  by  it.  Especially  is  this  true  of  urban  com- 
mimities,  where  opportunities  for  indiscriminate  and  impure  relations  of 
the  sexes  are  relatively  great.  Country  communities  enjoy  great  immunity 
by  comparison,  though  by  no  means  so  free  from  the  disease  as  some  would 
have  us  believe. 

Syphilis,  otherwise  known  as  lues,  popularly  termed  the  "pox,"  is  a 
"dyscrasic  or  constitutional  affection  of  the  type  known  as  Tilood  diseases,'" 
due  to  the  infection  of  the  human  organism  with  a  peculiar  morbific  prin- 
ciple, probably  a  germ  of  peculiar  pathogenic  properties,  unknown  as  an 
entity,  but  plainly  manifest  in  its  pathologic  results.  Its  manifestations 
are,  to  all  intents  and  purposes,  a  lesion  that  is  primarily  local,  followed  by 
a  succession  of  morbid  constitutional  manifestations,  appearing  at  variable 
intervals,  running  a  somewhat  definite  course,  and  being  more  or  less  amen- 
able to  treatment.  The  materies  morbi  of  syphilis  has  not  yet  been  isolated, 
although  we  are  justified  by  analogic  reasoning  and  comparison  with  other 
infections  in  accepting  the  hypothesis  that  it  is  a  micro-organism  possessed 
of  most  potent  evil  propensities.  The  researches  of  Lustgarten,  Doutrele- 
pont,  and  others,  pointing  to  a  specific  bacillus  as  the  cause  of  syphilis,  have 
made  an  impression  upon  its  pathology  that  has  been  felt  everywhere.  Al- 
though, up  to  the  present  time,  this  matter  is  barely  beyond  the  hypothetic 
stage,  it  has  served  to  elucidate  many  obscure  points  connected  with  the 
pathology  of  this  disease — of  which  more  anon.  In  many  respects  syphilis 
resembles  the  exanthemata,  inasmuch  as  it  is  transmissible  from  the  diseased 
to  healthy  individuals,  has  a  period  of  incubation,  a  stage  of  eruption,  an- 
other of  decline,  and  a  period  of  true  sequels.  A  very  minute  quantity  of 
germ-bearing  syphilitic  products  is  sufficient  to  produce  the  disease,  al- 

(332) 


HISTORY    OF    SYPHILIS. 


333 


though  it  is  fortunately  only  contagious,  and  not  infectious  in  the  true 
sense  of  the  term. 

The  wide  diffusion  of  syphilis  throughout  the  human  family  is  not 
fully  appreciated  by  the  physician,  as  a  rule,  until  after  some  years'  experi- 
ence in  private  practice,  when,  especially  if  his'  field  of  labor  lies  in  a  large 
city,  he  is  likely  to  conclude  that  no  one  is  above  suspicion.     This  state- 


Fig.  100.— Case  of  hereditary  syphilis  diagnosed  as  and  treated  for 
leprosy.     (After  Dumesnil.) 

ment  may  seem  rather  sweeping;  but  it  is  certain  that  syphilis,  like  acci- 
dents, is  liable  to  occur  in  the  best-regulated  families  and  often  serves 
to  explain  otherwise-obscure  cases  of  aristocratic  aches  and  invalidism. 
This  was  very  forcibly  impressed  upon  the  author  by  one  of  the  first  cases 
that  came  under  his  care  after  leaving  the  hospitals  to  enter  private  practice. 
A  lady  of  40,  moving  in  the  most  aristocratic  circles,  had  been  affected  for 


334 


SYPHILIS. 


some  months  with  what  had  been  diagnosed  and  treated  as  chronic  rheu- 
matism by  a  number  of  capable,  but  too  credulous,  physicians.  She  had  suf- 
fered with  osteocopic  pains  with  nocturnal  exacerbations  very  severely,  and 
for  two  months  had  been  unable  to  walk,  her  lower  extremities  being  par- 
tially paretic.  A  four  weeks'  course  of  antisyphilitic  treatment  relieved  her 
sj^mptoms  completely,  and  the  author  had  the  doubtful  satisfaction  of  being 
pronounced  "very  good  for  rheumatism"  as  a  reward  for  his  incredulity. 
Cases  of  this  kind  are  by  no  means  infrequent,  and  their  accurate  diagnosis 
and  successful  treatment  may  be  of  inestimable  value  to  the  young  phy- 
sician in  beginning  practice. 

The  origin  of  syphilis  is  not  definitely  known,  but  it  is  probably  quite 
an  ancient,  and  therefore  respectable,  disease,  inasmuch  as  it  is  more  than 
likely  that  some  of  the  forms  of  so-called  leprosy  of  Bible-times  were  in- 


Fig.  101. — Plantar  leprosy,  resembling  syphilis.     (After  Hitt.) 


stances  of  syphilis.  Indeed,  syphilis  and  leprosy  were  confounded  only  a 
few  centuries  ago.  jSTearly  all  the  "stock"  accounts  of  syphilis  state  that  the 
disease  appeared  in  Southern  Europe  in  the  latter  part  of  the  fifteenth 
century,  the  supposition  being  that  it  was  imported  from  America  by  the 
sailors  who  accompanied  Columbus  or  Amerigo  Vespucci  upon  their  ex- 
peditions. As  the  shop-worn  tale  runs,  the  morals  of  the  country  at  that 
time  being  none  too  rigid,  the  disease  spread  very  rapidly,  being  later  on 
mistaken  for  leprosy.  Irrespective  of  the  accuracy  of  this  interesting  and 
entertaining  little  account  of  the  disease,  its  recognition  in  every  part  of 
the  world  as  a  distinct  affection  seems  to  date  from  about  that  time,  although 
it  is  unquestionable  that  syphilis  was  known,  and  quite  well  understood, 
centuries  prior  to  the  Columbian  epoch.  That  leprosy  and  syphilis  should 
have  been  confused  in  ancient  times  is  in  nowise  surprising,  as  there  is  often 
a  certain  degree  of  physical  resemblance  between  the  two  diseases.     The 


HISTOET   OF    SYPHILIS. 


335 


accompanying  illnstrations  show  this  admirably.  One  of  these  cases  was 
mistaken  and  treated  for  leprosy.  Finally  coming  under  the  care  of  a  dis- 
tinguished dermatologist,  the  case  was  correctly  diagnosed  and  under  anti- 
syphilitic  treatment  recovered. 

Edmond  Dupuy  has  gathered  and  cited  authorities  that  tend  to  prove 
that  syphilis  existed  even  in  Europe  long  before  the  departure  of  Columbus 
on  his  first  voyage  of  discovery.^ 


Fig.  102. — Mixed  type  of  leprosy  simulating  syphilis. 


That  syphilis  was  known  among  the  aborigines  of  America  at  an  early 
period  is  shown  by  the  studies  of  the  distinguished  Prof.  Joseph  Jones 
upon  the  bones  of  skeletons  found  in  ancient  mounds  and  other  burial 
places  in  some  of  our  Southern  States.  Among  these  relics  were  found  un- 
mistakable evidences  of  syphilitic  osteitis,  caries,  nodes,  and  necrosis. - 


Le  Moyen  Age  Medical,  par  le  Dr.  E.  Dupuy. 
'New  Orleans  Medical  and  Surgical  Journal,  June,   1878. 


336  SYPHILIS. 

The  disease  was  described  by  the  Japanese  historians  several  thousand 
years  ago,  and  documents  are  still  in  existence  containing  ancient  descrip- 
tions of  the  affection  that  are  exceedingly  accurate.  This  would  indicate 
the  Asiatic  origin  of  the  disease,  it  having  been  brought  to  America  by  those 
nomadic  tribes  who  settled  this  country  some  centuries  ago  when  America 
and  Asia  were  united  by  the  peninsula  now  represented  by  the  Aleutian 
Islands. 

As  still  further  evidence  of  the  antiquity  of  syphilis  may  be  mentioned 
recent  translations  of  ancient  Chinese  medical  writings,  Avhich  show  that 
the  disease  was  known  in  China  two  thousand  years  ago.  The  Emperor 
Hoang  Ti  certainly  recognized  it,  as  his  writings  prove.  Moses  was  un- 
doubtedly familiar  with  the  disease:  a  fact  that  makes  it  still  more  ancient 
and  respectable. 

According  to  recent  researches  by  Leon  Duchesne,  syphilis  was  known 
in  Europe  fully  two  centuries  before  the  voyages  of  Columbus  and  Ves- 
pucci.^ In  a  compilation  of  surgery,  written  in  1250  by  Theodoric,  a 
Dominican  Monk,  an  entire  chapter  is  devoted  to  what  he  terms  the  malum 
mortuum:  a  disease  that  is  evidently  syphilis.  The  treatment  which  this 
author  recommends  is  certainly  modern  enough,  and  consists  of  mercurial 
inunctions — a  sad  commentary  upon  our  progress  in  the  therapeutics  of 
the  disease.  In  a  surgical  treatise  written  by  Lanfranc,  of  Milan,  in  1296, 
is  a  chapter  devoted  to  "Chancre  and  Ulcers  of  the  Penis  in  Man."  De- 
scriptions of  a  disease  that  is  undoubtedly  syphilis  occur  in  the  surgical 
works  of  Salicet  and  G-erard,  which  also  appeared  during  the  thirteenth 
century. 

During  the  earlier  years  of  its  existence  in  Europe  syphilis  is  said  to 
have  been  so  malignant  and  widely  disseminated  as  to  be  recognized  as  a 
form  of  plague  that  created  great  havoc  and,  in  fact,  nearly  annihilated  the 
various  armies  of  the  afQicted  countries.  The  disease  has  gradually  grown 
milder  in  type  until  at  the  present  day  very  severe  and  exceptional  cases 
have  come  to  be  classed  as  "malignant."  There  should  be  some  explanation 
for  this,  and  it  may  not  be  amiss  to  digress  slightly,  and  discuss  what 
appear  to  the  author  to  be  logical  reasons  for  the  steady  diminution  in  the 
virulence  of  syphilis. 

In  the  first  place,  it  is  obvious  that  improved  sanitation  and  personal 
hygiene,  with  a  steadily  increasing  knowledge  of  the  pathology,  and  more 
rational  measures  of  treatment  of  any  particular  infectious  disease  must 
eventually  result  in  modifying  its  severity.  This  has  been  especially  true 
in  the  case  of  syphilis;  but  there  is  another  and  more  powerful  influence 
that  is  constantly  manifesting  itself  in  the  case  of  contagious  diseases  in 
general,  viz.:  the  fact  that  some  diseases  occurring  in  individuals  of  one 
generation  impart  a  certain  degree  of  immunity  to  their  descendants. 


Journal  de  Medeeine  de  Paris. 


HEREDITY   AXD    IMilUXITY.  337 

A  very  interesting  article  bearing  upon  the  influence  of  heredity  and 
natural  selection  in  modifying  the  severity  of  different  contagious  diseases 
was  written  some  years  since  by  H.  M.  Lyman,  of  Chicago,  that  seems  to 
the  author  to  be  logically  applicable  to  syphilis  as  well  as  to  the  diseases  to 
which  the  originator  of  the  interesting  theory  applied  it.  Lyman  cites  as 
an  illustration  of  his  views  the  extraordinary  malignancy  of  measles  among 
the  natives  of  the  Sandwich  Islands,  some  years  ago.  These  people  were 
never  affected  b}^  measles  until  it  was  imported  by  the  whites,  consequently 
they  had  not  acquired  tolerance  of  the  disease.  Although  the  population  of 
the  islands  was  almost  decimated  at  the  time,  the  disease  has  steadily  de- 
creased in  malignancy  ever  since.  Another  illustration  cited  is  the  peculiar 
malignancy  of  variola  among  the  negro  race.  Small-pox  was  unknown  in 
Africa  until  imported  by  Europeans,  and  after  its  introduction  created  fear- 
ful havoc  among  the  natives.  It  has  probably  not  yet  had  time  to  become 
very  markedly  modified  in  the  negro, — as  it  undoubtedly  has  in  the  white 
race, — but  a  steady  modification  is  to  be  expected. 

When  an  epidemic  attacks  a  community  it  attacks  those  susceptible  to 
the  disease,  and  so  modifies  their  organisms  that  they  become  tolerant  of 
future  attacks.  This  tolerance  is,  in  a  measure,  transmitted  to  their  de- 
scendants. A  certain  number  of  individuals  are  insusceptible  to  the 
epidemic  influence,  and  consequently  escape  the  disease.  This  inherent  in- 
susceptibility is  also  transmitted  to  the  next  generation.  These  facts  illus- 
trate the  influence  of  heredity.  As  already  stated,  a  certain  number  of  indi- 
viduals are  primarily  immune,  and  consequently  escape  the  disease,  while 
susceptible  individuals  are  attacked,  with  a  fatal  result  in  those  least  able 
to  withstand  it.  This  illustrates  the  influence  of  natural  selection.  Apply- 
ing this  theory  to  syphilis,  it  may  be  readily  seen  that  the  disease  has  prob- 
ably destroyed  those  subjects  least  able  to  resist  it,  and  that  the  immunity 
acquired  by  exposure  to  its  influence  in  the  case  of  those  who  have  survived, 
together  with  the  primary  insusceptibility  of  a  certain  ]3roportion  of  indi- 
viduals, have  been  transmitted  to  successive  generations  until  at  the  present 
day  syphilis  is  a  comparatively  mild  affection.  It  is,  of  course,  admitted 
that  the  insusceptibility  of  one  generation  may  depend  upon  the  inheritance 
of  unequivocal  syphilis  from  the  parent-stock,  but  in  certain  instances  this 
transmitted  impression  is  very  attenuated. 

The  importance  of  a  careful  consideration  of  the  evolutionary  law  as 
bearing  upon  hereditary  modifications  of  constitution  produced  by  syphilis 
is  rather  underestimated  by  the  profession.  This  is  due  to  the  fact  that 
syphilis  may  appear  in  successive  generations,  not  as  syphilis  per  se,  but  as 
hereditary  perversions  of  growth  and  nutrition  due  to  its  morbific  influence 
somewhere  along  the  ancestral  line.  Malformations — such  as  talipes,  epi- 
spadias, hypospadias,  spina  bifida,  and  other  results  of  maldevelopment — 
may  possibly  owe  much  to  a  tainted  ancestr3^  Eickets  and  scrofulosis  are 
probably  in  many  cases  hereditary  syphilis  en  masque.     It  is  probable  that 


338  SYPHILIS. 

certain  cases  of  phthisis  and  spinal  caries  are  of  similar  origin,  and  depend- 
ent upon  hereditarily  faulty  structure  from  ancestral  syphilization. 

Duality  of  Syphilis  and  Chanckoid. — One  of  the  most  important 
results  of  modern  research  has  been  the  establishment  of  the  duality  of  the 
poisons  of  syphilis  and  chancroid.  The  experiments  proving  this  have  been 
numerous  and  conclusive,  yet,  strange  as  it  may  seem,  there  are  those  who 
continue  to  believe  in  their  unity.  Among  those  who  adhere  to  the  old 
theory  may  be  mentioned  Kaposi.  Many  prominent  English  surgeons  are 
also  o.f  this  belief;  hence  the  confusion  of  terms  existing  in  most  English 
works  upon  syphilis.  With  them,  chancroid  is  also  and  erroneously  termed 
"local  syphilis."  Jonathan  Hutchinson  in  his  Lettsomian  lectures  some 
years  ago  argued  that  chancroid  only  occurs  in  patients  who  have  at  some 
previous  time  had  syphilis, — i.e.,  that  it  is  a  syphilitic  sore  on  a  syphilis- 
immune;  so  that  he  is  practically  a  believer  in  unity.  Variance  of  opinion 
has  resulted  in  a  division  of  authorities  into  "unicists"  and  "dualists." 

The  obscurity  that  formerly  clouded  the  minds  of  surgical  authorities 
regarding  the  venereal  disease,  in  the  post-Hunterian  period  known  as  "the 
period  of  venereal  confusion,"  seems  very  remarkable  to  latter-day  surgeons, 
who  have  profited  by  the  errors  of  their  medical  forefathers.  As  already 
mentioned,  John  Hunter,  the  greatest  surgical  philosopher  of  the  eighteenth 
centur}',  believed  that  there  was  but  one  venereal  disease,  and  that  a  con- 
stitutional afi'ection.  He  believed  this  because  he  had  produced  constitu- 
tional syphilis  in  himself  by  inoculating  his  own  arm  with  gonorrheal  virus. 
He  labored  under  this  delusion  until  the  day  of  his  death.  Xearly  half  a 
century  later  Eicord  demonstrated  the  error  of  the  great  master  so  far  as 
the  independence  of  gonorrhea  is  concerned;  but  he  himself  did  not  recog- 
nize the  difference  between  syphilis  and  chancroid.  Some  years  later  their 
duality  was  shown  by  Bassereau:    one  of  Eicord's  own  pupils. 

It  is  imnecessary  to  enter  into  a  lengthy  discussion  of  the  dii?erent 
authorities  and  methods  of  research  proving  the  duality  of  the  two  poisons, 
for  the  fact  is  generally  accepted;  but  a  few  facts  bearing  upon  it  may  be 
profitably  mentioned.  It  is  easy  to  appreciate  the  clinical  force  of  one  of 
the  most  powerful  arguments  of  the  unicists,  viz.:  that  general  symptoms 
frequently  follow  an  apparently  non-indurated  simple  sore;  but  such  cases 
are  merely  exceptions  to  a  well-established  rule.  It  must  be  confessed  that 
very  innocent-looking  sores  are  followed  by  secondary  syphilis  sufficiently 
often  to  necessitate  caution  in  the  matter  of  prognosis  in  every  sore,  how- 
ever innocent-looking,  but  not  often  enough  to  shake  clinically-impressed 
convictions  as  to  the  duality  of  syphilis  and  chancroid.  When  chancroidic 
poison  is  deposited  upon  a  raw  surface  and  the  surface  is  cauterized  soon 
afterward,  no  chancroid  results.  .If,  however,  the  syphilitic  infection,  as 
contained  in  the  secretion  of  a  chancre  or  syphilitic  ulcer,  be  thus  inocu- 
lated and  the  wound  cauterized,  syphilis  will  result,  as  a  rule.  Hill  cauter- 
ized a  ruptured  frenum  twelve  hours  after  intercourse,  but  syphilis  developed 


DUALITY    OF    SYPHILIS    AND    CHAXCEOID.  339 

as  if  nothing  had  been  clone.  Fournier  canterized  a  chancre  six  hours  after 
its  appearance,  yet  syphilis  followed.  Excision  of  the  primary  sore  has  been 
practiced,  and  has  recently  been  revived,  but  has  not  as  yet  been  proved  to 
prevent  the  development  of  syphilis.  It  has  seemed  to  modify  it  in  certain 
instances,  and  in  a  number  of  personal  cases  the  subsequent  secondary  mani- 
festations were  very  mild;  this,  however,  proves  nothing.  The  facts  given 
are  sufficient  in  themselves  to  prove  the  non-identity  of  syphilis  and  chan- 
croid. Syphilis  is  essentially  constitutional  (even  if  primarily  local),  so  far 
as  its  clinical  manifestations  are  concerned;  while  chancroid  under  all  cir- 
cumstances is  a  purely  local  alfection. 

Attempts  at  the  inoculation  of  animals  with  syphilis  and  chancroid 
have  shown  a  marked  difference  between  the  two  diseases.  Syphilis  is  not 
generally  believed  to  be  transmissible  to  the  lower  animals,  while  chancroid 
is,  although  with  a  certain  amount  of  difficulty.  Depaul,  however,  speaks  of 
a  syphilitic  monkey,  and  some  years  ago  Martineau  claimed  to  have  produced 
a  hard  chancre  upon  the  penis  of  a  monkey.  The  animal  was  afterward  ex- 
hibited to  the  French  Academy,  with  apparently  unequivocal  secondary 
lesions,  which,  in  the  opinion  of  the  few,  proved  the  eommunicability  of 
syphilis  to  the  monkey.  The  monkey  inoculated  by  M.  Martineau  with 
syphilitic  virus  developed  chancres  twenty-eight  days  later.  These  were  fol- 
lowed by  papulo-erosive  and  diphtheroid  penile  lesions;  inguinal,  axillary, 
and  submaxillary  adenitis;  and  emaciation.  Later,  there  were  numerous 
patches  of  alopecia  on  the  head  and  back  and,  al^out  ten  months  after  the 
infection,  ulceration  of  the  mucous  membrane  of  the  palatal  vault.  Klebs 
has  claimed  that  he  has  successfully  inoculated  syphilis  upon  monkeys  and 
pigs,  the  experiments  upon  the  latter  being  most  questionable  in  results. 
Instances  have  been  reported  of  supposed  communication  of  syphilis  from 
man  to  the  lower  animals  by  unnatural  contact;  but,  so  far  as  the  author  is 
aware,  there  are  none  that  are  sufficiently  authentic  to  deserve  attention.^ 
As  might  be  imagined,  such  cases  are  quite  difficult  to  trace  and  verify  by 
actual  study  and  observation,  and,  in  addition,  the  sources  of  confusion  are 
manifold.  Xeumann,  in  numerous  experiments  upon  monkeys,  cats,  dogs, 
rabbits,  and  horses,  has  failed  to  produce  syphilis.  If  the  statement  that 
sj'philis  is  transmissible  to  the  monkey  alone  of  all  other  animals  be  true,  it 
would  seem  to  be  a  powerful  support  to  the  Darwinian  theory.  The  course 
of  syphilis  and  chancroid  is  sufficiently  distinctive  in  typic  cases.  In  con- 
clusion, it  might  be  asked  Avhy,  if  the  poiscns  of  syphilis  and  chancroid  are 
identic,  all  genital  sores  are  not  followed  by  constitutional  symptoms  when 
allowed  to  run  their  natural  course  without  treatment,  as  venereal  sores  so 
often  are  among  the  lower  classes. 

The  theory  of  the  origination  of  the  chancroidic  virus  de  novo,  that  has 
been  presented  in  connection  with  the  subject  of  chancroid,  would,  if  ab- 


^  Tide  chapter  on  chancroid. 


340  SYPHILIS. 

solntely  proved,  effectually  settle  the  question  of  unity.  The  author  has 
seen  numerous  cases  of  mixed  chancre  in  which  it  is  certain  that  the  chan- 
croidic  element  was  superadded  b}^  secondary  infection  of  the  syphilitic 
chancre.  In  one  of  these  cases  the  woman  with  Avhom  the  patient  had  in- 
tercourse after  the  hard  sore  had  developed  was  brought  to  the  author  for 
examination  and. found  to  have  chancroid.  Autoinoculation  settled  the 
question  of  the  character  of  the  sore  in  both.  This  form  of  mixed  sore  has 
not  been  alluded  to  by  surgical  writers,  so  far  as  the  author  is  aware,  and 
is  certainly  widely  different  in  its  history  and  course  from  ordinary  mixed 
infection.  The  author  has  seen  several  cases  where  a  patient  with  a  nearly- 
healed  chancroid  has  apparently  contracted  syphilis  by  inoculation  of  the 
ulcer.     Sources  of  error  in  diagnosis  are,  of  course,  admitted. 

If  chancre  and  chancroid  are  identic,  both  sores  should  be  autoin- 
oculable,  which,  as  is  well  known,  they  are  not,  this  property  being  limited 
to  chancroid  and  mixed  chancre. 

Yaeieties  of  Syphilis. — Svphilis  may  be  either  hereditary  (i.e.,  con- 
genital) or  acquired,  and  is  essentially  the  same  in  its  manifestations  in 
either  instance,  save  that,  as  we  shall  see  later  on,  hereditary  syphilis  has 
no  primary  stage.  Acquired  syphilis  is,  in  every  instance,  due  to  confronta- 
tion and  inoculation  with  a  peculiar  infection — presumably  a  pathogenic 
germ — derived  originally  from  some  individual  suffering  from  the  disease, 
and  which  infection  is  contained  either  in  the  secretion  of  a  syphilitic  lesion 
or  blood  from  a  syphilitic  subject. 

Speedy  Absorption  of  the  Infectious  Principle. — The  length  of  time 
necessary  for  the  absorption  of  the  sA'philitic  virus  after  the  inoculation  of  a 
healthy  tissue  is  unknown,  but  it  is  unquestionably  very  short,  although  no 
direct  experiments  have  been  made.  Abrasions  have  been  cauterized  within 
six  hours  after  suspicious  intercourse,  yet  syphilis  has  developed.  Berkeley 
Hill,  as  before  stated,  relates  a  case  in  which  he  cauterized  a  ruptured 
frenum  within  twelve  hours  after  exposure,  yet  syphilis  followed.  Numer- 
ous experiments  have  been  made  upon  poisons  bearing  an  analogy  to  the 
S5'philitic  infection,  which  are  very  instructive,  and  fairly  permit  certain 
conclusions  with  reference  to  syphilis.  The  experiments  with  the  virus  of 
vaccinia  have  been  especially  interesting.  Seven  children  were  vaccinated 
by  Martin,  and  the  site  of  the  operation  destroyed  by  Vienna  paste  at  periods 
varying  from  one  to  twenty-four  hours  thereafter.  None  of  the  children 
had  vaccinia;  but  all  save  one  were  protected  from  variola,  as  was  subse- 
quently proved  by  failure  to  inoculate  them  by  a  second  vaccination.  Clerc 
vaccinated  a  number  of  children,  destroying  the  spot  with  nitrate  of  silver 
one  hour  afterward:  vaccinia  was  not  prevented,  although  its  local  mani- 
festations were.  These  experiments  suggest  that  possibly  vaccinia  consists 
of  two  essential  elements, — a  local  and  a  constitutional, — permitting  the 
destruction  of  the  morbid  impression  causing  the  local  process,  without  any 
modification  of  the  constitutional  manifestations  of  the  virus.     "Whether  a 


ACQUIRED    IMMUNITY.  341 

similar  view  may  be  taken  of  syphilis  is  open  to  question.  There  are  some 
clinical  facts  that  apparently  support  such  an  assumption.  In  France  nu- 
merous experiments  with  the  poison  of  glanders  upon  animals  have  been 
made  by  different  surgeons.  The  site  of  inoculation  has  been  excised  within 
one  minute  after  the  introduction  of  the  virus;  yet  glanders  has  not  been 
prevented.  It  is  probable  that  the  infection  of  syphilis  is  not  absorbed  so 
cjuickly  as  some  other  poisons,  but,  reasoning  from  the  experiments  cited, 
the  period  required  must  be  very  short.  It  is  a  noteworthy  fact  that  the 
period  of  incubation  in  direct  inoculation  with  syphilis  is  relatively  brief. 
Acquired  Immunity. — Unlike  chancroid,  true  syphilis  is  very  rarely 
contracted  twice.  Many  cases  of  second  attack,  however,  have  been  re- 
ported. Diday  has  collected  twenty-five  such  cases,  twenty  of  which  were 
in  his  own  practice.  Such  cases  are  especially  interesting,  both  from  their 
rarity  and  the  fact  that  they  most  conclusively  prove  the  curability  of  syph- 
ilis, for,  were  the  disease  not  curable,  a  second  attack  would  be  impossible. 
A  few  of  Diday's  cases  were  contracted  during  the  existence  of  tertiary 
manifestations  of  the  previous  attack,  and  this,  too,  is  an  important  fact, 
as  tending  to  show  that  typic  "tertiary"  lesions  are  not  syphilitic  at  all, 
but  simply  non-transmissible  sequels.  It  is  probable  that  a  true  tertiary 
lesion  is  never  syphilitic  if  transmissibility  be  taken  as  the  criterion.  The 
longer  the  interval  between  the  first  and  second  attacks,  the  more  severe 
the  second  is  likely  to  be,  but  in  the  majority  of  cases  the  second  attack 
consists  in  the  primary  symptoms  alone,  without  further  manifestations  of 
the  disease.  This,  of  course,  lends  color  to  any  doubt  that  may  exist  as  to 
the  accuracy  of  the  diagnosis  in  different  cases.  The  author  has  seen,  in 
his  own  clinical  experience,  five  cases  that  were  apparently  second  attacks 
of  syphilis.  In  two  of  the  cases  the  diagnosis  of  the  first  attack  had  been 
made  by  men  of  unquestionable  skill,  one  of  whom  was  no  less  an  authority 
than  Bumstead.  There  is  no  doubt  jn  the  author's  mind  as  to  the  condition 
of  these  patients  when  they  came  under  his  care,  and  the  accuracy  of  the  first 
diagnosis  is  hardly  open  to  question.  The  folloAving  case  from  the  author's 
note-book  is  one  of  probable  second  infection: — 

Case. — A  man,  aged  30,  was  referred  to  the  aiithor  by  Dr.  F.  B.  Noreom,  of 
Chicago,  for  consultation  and  treatment.  He  was  suffering  from  a  well-pronounced 
tubercular  eruption,  some  of  the  lesions  of  which  were  as  large  as  small  plums;  alo- 
pecia, sore  throat,  adenitis,  and  mucous  tubercles  about  the  anus  and  scrotum  made 
the  case  a  very  typic  and  plain  one.  Under  careful  treatment  this  case  progressed 
most  satisfactorily,  the  lesions  clearing  up  within  six  weeks  and  never  recurring 
thereafter.  Two  years  after  the  original  infection,  during  which  time  the  patient 
was  under  constant  surveillance,  a  second  sore  appeared  on  the  site  of  the  original 
chancre,  which  was  precisely  like  the  latter,  and  apparently  as  typic  as  could  be 
desired.  This  appeared  on  the  twenty-sixth  day  after  exposure,  and  was  followed  by 
characteristic  mild  syphilitic  bubo  and  lymphitis.  These  symptoms  were  unyielding 
until  mercury  was  given.  They  then  disappeared,  and  the  patient  has  since  remained 
well. 


342  SYPHILIS. 

Sources  of  Fallacy  in  Diagnosing  Second  AttacJcs  of  Syphilis. — There 
are  several  sources  of  fallacy  in  diagnosing  a  second  attack  of  syphilis  that 
must  be  remembered.  1.  A  non-specific  general  eruption  ma}'  accompany 
chancroid.  2.  Impetigo  contagiosa — ectliA'ma — or  some  form  of  eczema 
may  be  mistaken  for  true  syphilis,  and.  if  it  follows  a  genuine  attack,  be 
cited  as  a  case  of  second  infection,  or  the  first  attack  ma}'  have  been  impetigo 
or  eczema  and  the  second  true  syphilis.  3.  A  chancroid,  or  mucous  patch, 
may  become  the  seat  of  such  marked  inflammatory  induration  that  it  is  mis- 
taken for  true  chancre.  4.  A  tertiary  gummy  ulcer  may  be  taken  for  hard 
chancre.  5.  There  may  possibly  be  such  a  thing  as  "recurrent  chancre." 
6.  Not  infrequently  chancre  almost  entireh'  disappears,  yet  a  slight  indura- 
tion remains,  which,  at  some  subsequent  period,  enlarges  into  a  similitude 
of  a  new  initial  sore. 

The  condition  termed  by  several  French  writers  recurrent  chancre  is 
probably  either  second  infection  or  gummy  ulcer  of  the  penis.  The  author 
does  not  believe  that  a  chancre  that  has  once  entirely  disappeared  ever  recurs. 

AxiMAL  Syphilis. — The  non-transmissibility  of  syphilis  to  the  lower 
animals,  with  the  exception  of  the  monkey,  as  claimed  by  Martineau,  had 
alread}'  been  mentioned.  It  is,  as  we  have  alread}'  seen,  a  demonstrable 
fact  that  syphilis  diff'ers  markedly  from  chancroid  in  this  respect.  But,  as 
is  well  known,  animals  also  have  venereal  diseases — i.e.,  affections  con- 
tracted only  through  sexual  intercourse. 

Maladie  du  Coit. — One  of  the  mo.st  interesting  studies  for  the  syph- 
ilographer  is  the  maladies  consequent  upon  impure  sexual  congress  in  the 
lower  animals.  The  only  authentic  and  accurately  described  disease  of 
apparently  venereal  origin  in  animals  is  the  doury,  la  dourine,  maladie  du 
coit,  or  syphilis  equine.  This  disease  has  been  described  at  various  epochs 
under  at  least  a  dozen  other  names  more  or  less  fallacious.  It  was  first 
described  by  Amnion,  a  celebrated  veterinarian  of  Prussia  in  1796.  Since 
that  time  many  interesting  brochures  have  appeared,  those  of  St.  Cyr^  and 
Laquerriere-  having  been  classics  upon  the  subject.  By  far  the  best  disser- 
tation upon  the  subject  in  all  its  phases  is  that  of  J.  Eollet  (de  Lyon).^ 
According  to  Eollet,  the  dourine  is  an  affection  of  long  duration,  the  evolu- 
tion of  which  should  be  divided  into  several  periods. 

First  Period. — This  comprises  the  ensemble  of  symptoms  constituting 
the  debut  of  the  disease,  and  differs  markedly  in  the  two  sexes. 

Injhe  Mare. — The  first  symptom  is  a  more  or  less  pronounced  edem- 
atous swelling  of  the  vulva — generally  unilateral.  This  is  hot,  slightly 
painful,  but  attended  by  most  intense  pruritus.  The  mucous  membrane  is 
red,  injected,  and  secretes  excessively.     A  distinct  discharge  soon  develops, 


^  Annales  de  deimatolcgie  et  de  syphilographie.  1877.  Xo.  4. 

-  Gazette  hebdomadaire  de  medecine  et  de  chirurgie,  1883,  Xo.  31. 

^  "Dictionnaire  encvclopediqiie  des  sciences  medicales."" 


MALADIE    DU    COIT.  343 

this  being  quite  tenacious.  Micturition  is  frequent,  the  urine  being  scanty 
and  thick,  containing  more  urea  tlian  normally  and  a  small  amount  of  albu- 
min. The  vulvo-vaginal  mucous  membrane  often  presents  a  polymorphous 
eruption,  which  may  be  papular,  vesicular,  pustular,  or  mixed  in  character. 
White  patches  sometimes  form  from  loss  of  pigment.  Follicular  hyper- 
trophy and  diphtheritic  ulcerations  are  not  unusual.  These  eruptions  run 
their  course  quite  rapidly,  cicatrization  being  complete  in  two  or  three 
weeks.  In  some  cases  the  process  becomes  chronic  and  persists  throughout 
the  disease. 

In  the  Stallion. — The  symptoms  are  not  so  marked  as  in  the  mare. 
Sometimes  the  animal  presents  no  evidences  of  disease,  its  existence  being 
recognized  only  by  the  contamination  of  the  mares  with  whom  he  copulates. 
When  symptoms  exist  they  consist  of  slight  heat  and  tumefaction  of  the 
penis  and  moderate  urethritis;  discharge  is  not  so  constant  as  in  the  female. 
There  is  frequent — sometimes  difficult — micturition;  marked  penile  edema 
and  apparent  penile  paralysis  sometimes  occur.  The  skin  of  the  penis  and 
scrotum  may  also  present  a  polymorphous  eruption.  These  may  appear  and 
disappear  many  times  during  the  course  of  the  disease.  Coitus  is  difficult 
and  painful,  often  impossible.  Erections  are  never  so  frequent  and  vigorous 
as  in  the  healthy  animal.  Ejaculation  sometimes  occurs  only  after  many 
attempts  to  cover  the  mare.  Fecundation  seems  to  take  place,  however, 
quite  constantly,  despite  the  probable  perversion  of  the  constitution  of  the 
semen.  The  testes  and  epididymes  may  be  swollen  and  tender.  In  both  male 
and  female  only  local  manifestations  of  disease  are  noticed  at  first.  The 
animal  may  present  all  the  appearances  of  perfect  general  health  for  a 
month  or  more.  Sometimes  a  little  sluggishness,  a  capricious  appetite,  or  a 
slight  and  irregular  elevation  of  temperature  are  noted  early;  the  animal 
grows  thin,  but  the  appetite,  perhaps,  keeps  up.  The  first  manifestation  of 
leanness  appears  in  the  rear  quarters  and  lumbar  region.  The  hind-quarters 
appear  to  give  way  from  time  to  time  as  if  the  animal  had  stumbled.  In  the 
regular  course  of  events  these  latter  symptoms  herald  the  onset  of  the  con- 
stitutional manifestations  of  the  disease. 

Second  Period. — This  period  presents  symptoms  affecting  chiefly  gen- 
eral nutrition  and  the  functions  of  the  nervous  system,  and  is  essentially 
the  same  in  both  sexes.  The  animal  grows  sensibly  leaner,  the  muscles  of 
the  croup,  lumbar  region,  and  anterior  femoral  region  being  chiefly  affected. 
General  sensibility  is  sometimes  greatly  exaggerated,  chiefly  in  the  lumbar 
region,  where  a  slight  pinch  may  cause  great  pain.  The  functions  of  loco- 
motion are  impaired  and  the  animal  favors  his  hind-quarters,  inclining  to 
rely  upon  the  forelegs  for  support.  In  action  the  hind-quarters  ill  support 
the  body-weight,  a  stumbling  gait  being  the  result;  more  or  less  lameness, 
apparently  in  the  hamstrings,  fetlocks,  or  knees,  is  observable.  This  is  un- 
attended by  any  appreciable  lesion,  and  disappears  spontaneously  in  from 
four  to  twelve  days.    At  the  same  time  paralysis  of  the  lips,  cheeks,  and  eye- 


344  SYPHILIS. 

lids  supervenes;  this  may  be  temporary  or  permanent.  The  paresis  of  the 
posterior  members  may  pass  away  or  develop  into  true  paraplegia.  Accord- 
ing to  St.  Cyr,  the  affected  muscles  retain  their  electrosensibilit}',  even  when 
atrophied.  It  is  at  this  time  that  the  stallion,  without  becoming  truly  im- 
potent, becomes  less  passionate,  erections  being  less  frequent  and  feebler 
than  in  the  normal  condition;  mounting,  at  first  difficult,  may  eventually 
become  impossible  as  paresis  becomes  more  marked. 

A  very  striking  symptom — from  the  stand-point  of  syphilitic  analogy 
especially — is  the  development  of  round,  slightly  prominent  cutaneous 
tumors  or  elevated  plaques,  varying  from  the  size  of  a  silver  quarter  to  that 
of  the  palm  of  the  hand.  These  are  soft,  almost  painless,  and  become  firmer 
later  on.  They  resolve  in  from  eight  to  fifteen  days,  more  or  less,  leaving 
no  cicatrices  or  other  evidences  of  their  ephemeral  course.  The}^  may  recur 
many  times  during  the  course  of  the  disease. 

In  the  mare — becoming  pregnant  after  impure  coitus — abortion  often 
occurs  between  the  third  and  sixth  month  of  utero-gestation. 

The  second  period  of  the  disease  may  last  for  some  time,  one  or  two 
months  in  some  cases,  in  others  six  or  eight  months,  or  even  a  year  or  more. 

There  are  observed  in  the  course  of  the  disease  alternations  of  aggrava- 
tion and  amelioration. 

Such  complications  may  occur  as  orchitis,  mastitis, — sometimes  going 
on  to  suppuration, — ophthalmia,  abscesses  in  different  locations,  nasal  dis- 
charge, and  adenopathy — local  or  general. 

Third  Period. — In  this  stage  of  the  disease  all  of  the  symptoms  become 
aggravated,  emaciation  increases,  even  marasmus  supervenes,  parah'sis  be- 
comes general,  and  the  animal  lies  down  constantly.  Suppurating  and 
sloughing  areas  over  various  bony  prominences  —  "'bed-sores"  —  develop. 
Death  may  result  from  a  gradual  exacerbation  of  the  S3'mptoms — hj  asthe- 
nia, or  from  some  intercurrent  affection,  hypostatic  pneumonia  being  fre- 
quently the  immediate  cause  of  death. 

Prognosis.  —  Eecovery  from  maladie  du  colt  is  rare,  death  occurr'ng 
after  some  months  or  perhaps  not  under  a  year.  Even  two  years  has  been 
known  to  elapse  before  a  fatal  result  has  occurred. 

Morhid  Anatomy. — Congestion  of  the  lumbar  cord  and  its  envelopes, 
softening,  chiefiy  of  the  gray  matter,  serous  subarachnoidean  effusion,  and 
thickening  of  the  lumbo-sacral  plexus,  which  shows  interstitial  and  periph- 
eral infiltration  —  neuritis.  "When  paralysis  has  become  general  there  is 
medullary  softening  and  gelatiniform  infiltration  of  the  cervico-dorsal  and 
dorso-lumbar  nerves. 

The  nerve-alterations  are  found  chiefly  in  the  posterior  limbs.  The 
nerves  are  swollen  from  a  yellowish  infiltration  of  the  neurilemma  and 
nerve-tubules.  A  certain  proportion  of  nerve-fibers  become  markedly  de- 
generated. The  alteration  of  the  cord  is  most  marked  at  the  dorso-lumbar 
junction,  where  there  are  distinct  areas  of  softening,  especially  in  the  gray 


MALADIE    DU    COIT.  345 

substance.  The  brain  has  been  found  in  a  similar  condition  of  softening, 
presenting,  moreover,  a  markedly  hyperemic  and  more  or  less  dusky  appear- 
ance. The  muscles  are  pale,  atrophied,  and  in  a  condition  of  fatty  degen- 
eration, resembling,  according  to  Eaynol,  boiled  meat.  The  bones  are  very 
friable,  especially  the  femurs.  (The  profoundly-trophoneurotic  character 
of  the  disease  at  once  suggests  itself.)  The  bone-marrow  is  soft,  diffluent, 
and  contains  extravasations.  The  joints  present  evidences  of  synovitis,  the 
ligaments  and  cartilages,  moreover,  being  softened.  Hypertrophy  or  at- 
rophy of  the  testes,  thickening  of  the  epididymes  and  cords,  and  hyperemia 
of  the  principal  viscera  may  be  found.  The  lymphatic  glands  and  peri- 
glandular tissues  are  the  seat  of  a  yellowish  gelatiniform  infiltration.  This 
exudation  is  the  characteristic  macroscopic  feature  of  these  cases. 

Contagiousness. — Some  observers  have  claimed  that  la  dourine  is  non- 
contagious and  is  a  simple  paraplegia.  Others  claim  to  have  seen  penile 
ulcerations  in  stallions  which  had  covered  many  mares  without  conveying 
contagion.  Still  others  claim  that  the  disease  may  occur  without  coitus 
(which  is  not  surprising).  There  would  seem,  however,  to  be  no  doubt  of 
the  contagiousness  of  the  disease.  It  does  not  occur  save  in  breeding  ani- 
mals nor  before  coitus.  Hertwig  reports  numerous  cases  directly  traceable 
to  the  procreative  act.  Experiments  by  direct  inoculation  have  justified  the 
deductions  from  clinical  observation.  The  germ  of  the  disease  is  as  yet  un- 
known. There  would  seem,  hoAvever,  to  be  little  doubt  of  its  microbial 
origin. 

Analogy  with  Syphilis. — Beginning  with  an  old  Arabian  belief,  it  has 
long  been  suspected — and,  indeed,  even  claimed — in  certain  quarters  that 
la  dourine  was  a  derivative  of  human  syphilis  through  the  bestial  variety 
of  sexual  perversion.  Like  most  popular  and  vulgar  notions,  this  has  never 
been  proved  authentically.  This  fact,  however,  does  not  prove  the  impos- 
sibility of  such  an  origin  of  the  disease.  Many  comparisons  have  been  made 
of  the  various  periods  and  lesions  of  doury  and  syphilis;  but,  aside  from  a 
strong  analogy,  we  are  still  as  far  from  securing  proofs  of  their  kinship  as 
ever.     As  Saint  Cyr  has  sagely  observed: — 

Human  syphilis  and  the  maladie  du  co'it  of  the  horse  present  strong  points 
of  similarity.  They  are  both  virulent  general  affections  habitually  contracted  during 
sexual  congress.  But  the  two  diseases  are  none  the  less  distinct  and  independent 
varieties,  bearing  no  more  relation  to  each  other  than  sheep-rot  does  to  human  variola. 

While  this  may  be  true  as  syphilis  and  la  dourine  are  seen  to-day,  it 
must  be  remembered  that  a  correlation  of  origin  is  not  without  the  bounds 
of  evolutionary .  possibilities.  Mankind,  however,  unquestionably  has  a 
monopoly  of  syphilis. 

Lancereaux  claims  to  have  observed  venereal  ulcer  of  a  purely  local 
character  in  the  equine  species.  His  observations,  however,  lack  confirma- 
tion.    The  local  ulcers  that  he  describes  are  probably  cases  in  which  la 


346  SYPHILIS. 

dourine  has  been  imperfectly  studied,  and  in  which  prominent  local  symp- 
toms have  existed,  with  superadded  pus-infection. 

Eacial  Susceptibility. — There  is  said  to  be  a  great  difference  in  the 
susceptibility  of  different  races  to  the  ravages  of  sjqDhilis:  e.g.,  it  is-  popu- 
larly supposed  to  be  more  severe  among  the  Chinese  than  among  white  peo- 
ple; and  it  has  been  asserted  by  the  laity  that  the  disease  is  much  more 
severe  in  the  Caucasian  where  it  has  been  contracted  from  the  Chinese  or 
negro  race.  The  author  has  investigated  this  matter  so  far  as  possible,  but 
has  been  unable  to  verify  the  popular,  impression.  It  is  not  probable  that 
the  disease  is  any  more  severe  in  the  dark-skinned  races  than  in  the  white, 
excepting  in  the  case  of  the  negro,  save  when  the  hygienic  surroundings  or 
personal  habits  are  in  favor  of  the  white  race.  Were  it  not  for  such  favor- 
able influences,  the  disease  should  be  severer  in  the  white  race — reasoning 
along  evolutionary  lines,  and  again  excepting  the  negro.  Opinions  differ 
as  to  this  point.  Dr.  Henry  E.  Carter,  who  has  studied  the  subject  carefully, 
says  that  enlarged  and  suppurating  glands,  rheumatoid  pains,  and  synoviaV 
inflammations  are  more  frequent  in  negroes  than  in  whites.  Mucous 
patches,  nodes,  and  caries  are  less  marked  than  the  preceding  lesions,  but 
are  more  pronounced  than  in  the  Caucasian. 

Effects  of  Occupation.  —  Different  occupations  have  been  said  to 
modify  the  effects  of  syphilis,  but  the  question  has  a  general  rather  than  a 
special  bearing  upon  the  disease.  Obviously,  such  occupations  as  tend  to 
produce  anemia,  debility,  and  nervous  or  mental  strain  favor  a  severe  course 
of  syphilis,  with  many  and  various  complications.  Fournier  saj^s  that  gam- 
blers, stock-brokers,  and  people  leading  similar  lives  are  liable  to  a  pecul- 
iarly precocious  course  of  luetic  evolution,  and  succumb  very  rapidly  to  the 
disease.  They  are  peculiarly  liable  to  cerebral  s3qDhilis.  The  peculiar  emo- 
tional life  of  these  jDeople  engenders  a  vasomotor  instability  that  is  pecul- 
iarly favorable  to  leucocytic  exudation  of  any  type.  The  same  fact  is  illus- 
trated by  the  negroes,  in  whom,  before  the  war,  syphilis  was  of  a  much 
milder  type  than  now,  because  speculative  emotional  alternations  were  rare 
among  them,  and  hence  circulatory  changes  did  not  alternate  with  great 
rapidity. 

Incubation-peeiod  of  Syphilis. — After  the  poison  of  syphilis  has 
been  absorbed  a  certain  period  elajDses  before  its  morbid  effects  become 
manifest.  This  period  is  known  as  the  stage  of  incubation,  and  lasts,  upon 
the  average,  about  twentj^-one  days,  but  varying  considerably  from  this  in 
different  cases.  Fournier  relates  a  case  in  which  the  period  was  seventy-five 
days;  Guerin,  one  of  seventy-five  da5rs;  and  the  author  has  noted  a  case  of 
seventy  days.  Instead  of  being  prolonged,  the  period  may  be  shorter  than 
iisual;  thus  Hammond  relates  one  of  three  days,  and  Dr.  N"ott,  of  Xew 
York,  since  deceased,  reported  his  own  case  as  developing  within  twenty- 
four  hours  after  wounding  his  finger  in  023erating  upon  a  syphilitic  subject. 
Taylor  reports  a  case  in  which  the  initial  lesion  appeared  upon  the  second 


BACILLUS    OF    SYPHILIS.  3^7 

day,  induration  upon  the  fonrth  da}',  and  general  sjanptoms  during  the 
sixtli  week,  and  another  in  whicli  the  chancre  appeared  at  the  end  of  the 
first,  and  the  general  symptoms  during  the  fifth  week.  It  may  be, accepted, 
as  a  practical  rule,  that  true  chancre  does  not  appear  before  the  tenth  day. 
Any  sore  appearing  prior  to  that  time  is  probably  chancroid  or  some  simple 
affection,  while  any  appearing  later  is  quite  likely  to  be  true  chancre.  It 
must  not  be  forgotten,  however,  that  the  "probable"  chancroid  may  be 
proved  to  be  a  case  of  mixed  infection  by  the  subsequent  appearance  of 
typic  induration.  This  "is  a  useful  practical  rule  to  remember,  although 
it  must  be  confessed  that  it  is  often  of  little  service  in  diagnosis,  inasmuch 
as  the  majority  of  individuals  contracting  venereal  disease  are  in  the  habit 
of  indulging  promiscuously  in  intercourse,  and  are  therefore  absolutely  un- 
able to  determine  which  of  their  numerous  adventures  was  the  unlucky  one. 
This  source  of  fallacy  usually  develops  on  careful  questioning.  Whenever 
the  induration  of  a  sore  is  absolutely  characteristic,  we  are,  of  course,  in 
nowise  dependent  upon  the  period  of  incubation  for  a  diagnosis. 

A.  Bernard  found  that  in  sixtT-nine  cases  of  venereal  sore,  inclusive  of 
chancre  and  chancroid,  the  incubation  period  varied  from  one  to  fifty-six 
daj'S,  and  calls  attention  to  the  apparent  preference  for  multiples  of  .seven 
as  the  incubation  period  in  a  large  proportion  of  cases.  This  was  true  of 
fort3^-three  out  of  his  sixty-nine  recorded  cases.  Fournier  found  this  pecul- 
iarity in  twenty  out  of  forty-five,  and  Lowndes,  in  twenty-five  out  of  fifty 
cases  of  inoculation.^  It  is  unfortunate  that  these  authors  are  not  more 
explicit  in  their  use  of  the  terms  chancre  and  venereal  sore.  In  drawing 
deductions  as  to  the  clinical  history  of  genital  lesions  differentiation  must 
be  most  accurate,  else  the  value  of  such  observations  is  greatly  impaired. 
There  has  been  much  looseness  of  nomenclature  among  syphilographers. 
Thus,  German  writers  apply  the  term  chancre  only  to  the  soft  sore.  Chan- 
croid is  variously  known  by  diiferent  authorities  b}'  the  terms  soft  chancre, 
non-indurated  chancre,  simple  chancre,  non-infecting  chancre,  local  svph- 
jlis,  and  contagious  local  ulcer  of  the  genitals. 

Bacillus  of  Syphilis. — The  author,  although  believing  in  the  germ- 
origin  of  syphilis,  regards  the  bacillus  claimed  to  have  been  discovered  by 
Lustgarten  as  yet  to  be  proved.  In  any  event,  its  existence  does  not  modify 
the  patholog}^  of  the  disease,  for  Lustgarten  claims  that  it  acts  by  incorpo- 
rating itself  with  the  white  blood-corpuscles — a  fact  worthy  of  note. 
Neisser  favors  the  bacillus  theory  of  syphilis,  but  he  is  much  less  dogmatic 
than  Lustgarten.  Ehrlich  and  Birch-Hirschfeld  also  advocates  the  bacillar 
doctrine.  Klebs,  Aufrecht,  Bergmann,  and,  following  them,  Barduzzi. 
claim  that  a  micrococcus  of  a  peculiar  character  exists  in  the  lymphatic 
vessels  and  glands  of  syphilitics.    As  Lustgarten's  investigations  have  gained 


^  British  Medical  Journal,  September  23,  1883. 


348  SYPHILIS. 

more  credence  than  those  of  his  predecessors,  the  author  appends  his  orig- 
inal description  of  the  hacillns  of  syphilis. 

I  have  succeeded  in  showing,  in  microscopic  sections  of  two  syphilitic  chancres 
and  one  syphiloma,  bacilli  which  are  perfectly  characterized  by  their  color,  reaction, 
form,  and  relative  position.  These  bacilli,  which  have  been  found  in  all  of  the 
examined  sections,  although  in  slightly  varying  quantity,  represent  slim,  straight,  or 
somewhat-curved  little  rods  of  about  the  same  size  and  the  same  appearance  as  the 
bacilli  of  tuberculosis.  They  are  always  found  either  single  or  in  small  groups, 
inclosed  in  lymphoid,  somewhat-distended  cells,  and  show  under  a  powerful  micro- 
scope light  spots  similar  to  those  which  Koch  regards  as  "spores"  in  the  tubercle 
bacilli.  The  method  of  coloring,  about  which  I  shall  report  in  a  future  and  more 
exhaustive  paper,  makes  it  possible  to  distinguish  the  bacilli  of  syphilis  both  from 
the  bacilli  of  lepra  and  tuberculosis,  and  from  all  other  pathogenic  bacteria  as  yet 
known.  The  fact  that  the  former  are  always  inclosed  in  cells  excludes  the  possibility 
of  deceptions  by  putrid  formations,  and  so  on.  I  never  could  observe  anything  like 
cocci,  and  I  emphasize  this,  because  a  number  of  investigators  (deceived  by  more  or 
less  important  errors)  have  regarded  them  as  specific  micro-organisms  of  syphilis  (as 
Birch-Hirschfeld  and  others). 

The  latest  claimant  for  bacteriologie  fame  in  syphilis  is  von  ISTiessen, 
of  Wiesbaden.  The  conclusions  to  which  he  has  arrived  from  his  researches 
are  as  follow: — 

1.  Syphilis  is  a  chronic  infectious  disease  of  the  blood,  and  is  transmitted  to 
other  tissues  of  the  body  by  the  lymphatics,  through  the  latter  system  the  contagium 
being  first  conveyed  to  the  blood. 

2.  The  contagium  of  syphilis  in  every  case  and  in  every  stage  of  the  disease  from 
the  moment  of  its  entrance  into  the  blood  is  demonstrable  through  staining  and 
cultivation.  In  many  cases  it  is  found  in  the  urine.  It  is  also  possible  to  find  it  in 
the  milk,  semen,  saliva,  sweat,  and  excrement. 

3.  In  diseases  other  than  syphilis,  or  where  it  is  complicated  with  other  diseases, 
the  contagium  cannot  be  found  in  the  blood. 

4.  The  cause  of  syphilis  is  a  pleomorphous  bacillus  which  is  closely  related  to 
the  more  highly  organized  fungi. 

5.  The  detection  of  the  syphilis-germ  in  the  blood  is  an  absolutely-sure  criterion 
of  the  presence  of  syphilis,  and  is  therefore  of  the  greatest  diagnostic  value  in  doubtful 
cases  requiring  diflferential  diagnosis. 

6.  Syphilis  in  aU  stages  is  inheritable  and  communicable.  This  applies  also  to 
rabbits,  which  can  be  infected  experimentally. 

7.  With  the  therapeutic  measures  known  up  to  the  present  time,  syphilis  is 
absolutely  incurable.    Relative  healing  denotes  only  a  latent  state. 

Medical  art,  therefore,  has  yet  to  find  a  certain  curative  for  syphilis.' 

Von  Niessen's  statements  are  certainly  dogmatic  enongh,  and  sulTi- 
ciently  startling  to  demand  abundant  confirmation  before  we  are  warranted 
in  accepting  them  as  proved. 

The  I^TIT1AL  Lesion. — Induration  of  a  peculiar  type  is  the  distinguish- 
ing feature  of  chancre;    the  manner  of  its  formation  and  its  histologic 


'  Centralblatt  fiir  Bakteriologie. 


PEIMAEY    LOCAL    CHANGES.  349 

characters  are  consequent!}^  a  matter  of  considerable  imiDortance.  Inasmuch 
as  the  chancre  is  the  type  of  all  lesions  of  active  sjqDhilis,  this  brings  us  to 
the  consideration  of  the  pathologic  changes  produced  by  the  disease.  The 
study  of  the  subject  should  naturally  begin  with  the  consideration  of  the 
primary,  or  initial,  lesion,  and,  beginning  at  the  seat  of  infection,  a  num- 
ber of  quite  important  tissue-changes  occur: — 

The  starting-point  of  syphilis  is  the  absorption  of  a  peculiar  morbific 
principle,  or  contagium,  which,  although  unknoAvn  as  an  entity,  is  only  too 
plainly  manifest  in  its  pathologic  effects.  The  most  probable  view  of  the 
nature  of  the  infection  is  that  it  is  a  germ  of  undetermined  type.  Otis 
claims  that  the  contagium  consists  of  a  degraded  infectious  cell  of  very 
minute  proportions,  a  view  that  is  in  nowise  inconsistent  with  the  germ- 
theory,  this  cell  having  been  primarily  infected  by  the  germ  and  acting  as 
a  carrier  of  infection  thereafter.^  However,  deficient  though  we  may  be  in 
jDositive  knowledge  of  the  nature  of  the  syphilitic  micro-organism,  we  at 
least  have  tolerably  definite  views  of  the  manner  of  its  action. 

Peimary  Local  Chaxges  FRo:\r  Infection. — The  first  effect  of  the 
S3qDhilitic  infection  is  the  j^roduction  of  a  gradually-increasing  accumula- 
tion of  white  blood-cells  or  lymph-cells  at  the  site  of  inoculation,  which  is 
brought  about  by  a  modification  of  the  normal  leucocytes  and  connective- 
tissue  elements  produced  by  the  S3^philitic  infection.     This  modification 


^  The  author  still  believes  the  views  expressed  by  F.  X.  Otis,  in  his  "Physiologic 
Pathology  of  Syphilis,"  to  be,  in  the  main,  the  most  logical  and  practical  of  any  thus 
far  advanced.  With  certain  modifications,  necessitated  by  the  acceptance  of  the  germ- 
theory  of  syphilis,  the  author  has  not  altered  his  views  upon  this  point  since  the  publi- 
cation of  his  own  lectures  on  syphilis  in  1884.  The  theory  of  syphilitic  pathology  advo- 
cated by  Otis  was  in  nowise  original  with  that  gentleman,  although  he  deserves  great 
credit  for  elaborating  upon  it  and  presenting  it  in  a  rational  and  intelligible  form. 
A  similar  theory  was  advanced  by  ISTisbet  in  1788,  and  revived  in  1863  by  Sperino. 
li.  W.  Taylor  ojjposes  the  A^ew  of  syphilitic  pathology  expounded  by  Otis,  upon  the 
ground  that  the  theory  demands  that  we  should  "assume  certain  fancies,  in  the  ab- 
sence of  definite  facts,  and  felicitate  ourselves  with  the  idea  that  we  know  how  syphilis 
Avorks  in  the  system,  when  the  truth  is  that  we  do  not."  Such  argument,  if  univers- 
ally applied  to  the  science  and  art  of  medicine,  would  tend  to  demolish  all  rational 
theorizing.  The  amount  of  positive  knowledge  of  the  modus  operandi  of  certain 
pathologic  influences,  and  of  our  therapeutic  resources  for  their  cure,  is  rather 
meager,  according  to  the  standard  by  which  Taylor  estimates  the  value  of  Otis's 
views.  Taylor  states  that  Otis  assumes  that  the  syphilitic  virus  consists  of  "disease- 
germs,"  and  that  "the  syphilitic  virus  coagulates  the  superficial  tissue-fluids,  caus- 
ing obstruction  to  the  circulation  and  attraction  to  the  spot  of  wandering  white 
corpuscles,  which,  by  their  ameboid  movement,  entrap  the  specific  disease-germ." 
Otis  does  not  speak  of  disease-germs,  but  of  diseased  germinal  cells.  As  for  the 
entrapping  of  the  germ  by  the  leucocyte,  it  is  a  pity  that  Otis  did  not  express 
himself  in  the  words  attributed  to  him  by  Taylor.  If  he  had,  he  would  have  fore- 
stalled the  valuable  discoveries  and  widely-accepted  theories  of  Metchnikoff.  In 
Taylor's  misinterpretation  of  the  views  of  Otis  he  builded  wiser  and  more  prophetic 
than  he  knew. 


350  SYPHILIS. 

probably  begins  immediateh^,  or,  at  least,  very  soon  after  the  infection  takes 
place,  but  is  more  or  less  gradual  in  manifesting  itself;  hence  we  have  a  cer- 
tain period  elapsing  before  evidences  of  its  action  are  exhibited. 

The  SypMlized  Cell  (BesiadecJvi,  Otis,  et  al.). — The  accumulated  cells, 
previously  normal,  contain  the  germs  of  the  syphilitic  infection,  and  their 
constitution  is  now.  greatly  modified.  They  have  become  larger,  more  gran- 
ular, and  contain  numerous  nuclei;  are  infectious,  and  have  their  powers 
of  proliferation  and  ameboid  movement  exaggerated.  In  addition  they 
present  a  marked  tendency  to  retrograde  metamorphosis.  When  removed 
from  their  original  situation  to  the  tissues  of  a  healthy  individual,  these 
cells,  by  virtue  of  their  infectiousness — i.e.,  by  virtue  of  the  syphilitic  germs 
they  contain — produce  changes  in  the  normal  leucocytes  in  their  new  en- 
vironment, exciting  rapid  proliferation  in  them,  as  well  as  undergoing  rapid 
changes  themselves. 

Modus  Operandi  of  the  SyphiUzed  Cell. — Let  us  consider  the  action 
of  the  infected  cell  —  the  "syphilitic  germinal  celF^  of  Ot's  —  upon  the 
ijj3rmal  leucocyte.  It  is  claimed  that  through  degradation  the  syphilitic 
germinal  cell  may  be  but  Vioooon  of  an  inch  in  diameter, — being  perhaps 
merely  one  of  the  nuclei  of  some  infected  and  degraded  leucocyte, — but  re- 
taining all  its  morbid  powers  of  proliferation  and  ameboid  activity,  the 
latter  being  especially  marked.  As  the  white  blood-cell  or  normal  leucocyte 
is  ^/osoo  of  ^^  iiich  in  diameter,  it  is  obvious  that,  by  virtue  of  the  peculiar 
affinity  of  the  infection-carrying  cell  for  it,  the  two  may  become  incorpo- 
rated, with  the  resulting  modification  of  the  leucocyte  that  has  been  de- 
scribed. The  theory  of  phagocytosis  applies  here,  although  in  this  instance 
the  phagocytic  action  of  the  leucocyte  is  feeble  by  comparison  with  the 
pathogenic  power  of  the  materies  morhi  of  the  infection. 

By  supposing  the  incorporation  of  a  bacillus,  instead  of  the  hypothetic 
cell  described,  with  the  leucocyte,  wq  can  at  once  harmonize  the  bacillar 
theory  of  the  origin  of  syphilis  with  its  "physiologic  pathology,"  and  thus 
put  the  latter  upon  a  probably-secure  basis.  The  hypothesis  of  a  germ  is 
much  more  logical  than  that  of  a  minute  degraded  cell  or  cell-nucleus. 

AVhether  the  infecting  principle  be  a  degraded  cell  of  poisonous  prop- 
erties, a  bacillus,  or  a  cell  containing  a  bacillus — the  two  latter,  one  or  both, 
being  most  likely — is  of  no  importance  in  the  subsequent  history  of  syph- 
ilitic events.  These  considerations  do  not  militate  against  the  plausibility 
and  practicality  of  the  views  of  syphilitic  pathology  as  Besiadecki  and  Otis 
originally  jiresented  them,  nor  do  they  controvert  the  belief  that  a  knowl- 
edge of  the  syphilized  cell — a  thorough  comprehension  of  its  life-history, 
properties,  and  mode  of  progression — is  the  key  to  the  study  of  syphilis. 
Just  as  the  leucocyte  is  the  primordial  cell  in  the  normal  physiologic  proc- 
esses of  groAvth,  so  is  it  the  basis  of  all  pathologic  processes — and  particu- 
larly those  of  syphilis — when  it  is  modified  in  the  manner  peculiar  to  the 
particular  morbid  change  in  the  tissues. 


I 


MIGEATIOX    OF    THE    SYPHILITIC    CELL.  351 

Taking  as  oiir  point  of  departure  the  initial  lesion  of  syphilis,  we 
observe  a  localized  proliferation  of  the  now  infected  and  perverted  cells, 
and,  following  the  infection  in  its  course,  thickening  of  the  lymphatic  ves- 
sels and  enlargement  of  the  lymphatic  glands  produced  by  this  same  cell- 
accumnlation  are  found. 

After  a  time,  infection-bearing  cells — or  perhaps  independent  micro- 
organisms— free  themselves  from  the  initial  accumulation,  travel  on  through 
the  lymphatics,  enter  the  receptaculum  chyli,  and  are  finally  emptied  into  the 
circulation  by  the  thoracic  duct,  to  be  then  driven  to  the  superficies  of  the 
body,  central  nervous  system,  and  viscera  with  the  general  blood-current. 
Various  secondary  phenomena  now  occur  in  the  different  tissues,  and  we 
will  briefly  consider  some  of  them:  General  enlargement  of  the  lymphatic 
glands  occurs — general  adenopathy — as  a  result  of  (1)  the  proliferation  of 
the  cells  carried  to  them  by  the  blood,  (2)  the  proliferation  of  their  own 
lymphoid  and  connective-tissue  elements  under  the  stimulus  of  the  infection 
brought  by  the  syphilized  cells,  and  (3)  an  accumulation  of  infected  ger- 
minal material  collected  by  the  absorbents  from  the  superficies  of  the  body. 
Engorgement  of  the  fauces  and  phar3mx  now  occurs,  due  to  a  localized  cell- 
proliferation  and  accumulation  in  the  rich  net-work  of  lymphatics,  which, 
as  will  be  seen  later  on,  is  a  marked  feature  of  the  anatomy  of  the  fauces, 
tonsils,  and  phar3^nx.  Mucous  patches  are  likely  to  occur,  and  are  simply 
quasipapules  upon  moist  mucous  surfaces,  due  to  a  circumscribed  collection 
of  the  characteristic  cells, — constituting  syphilitic  granuloma  in  whatever 
lesion  it  may  be  found.  The  same  description  will  apply  to  the  true  papule 
upon  the  integumentary  surfaces.  This  papule  may  have  an  excessive  ac- 
cumulation of  cells  and  become  a  tubercle,  or  from  pressure  upon  and  inter- 
ference with  the  nutrition  of  the  normal  tissue-elements  by  the  cells  in 
combination  with  their  own  tendency  to  retrograde  metamorphosis,  with  or 
without  complicating  pus-infection,  a  pustule  perhaps  forms  that  may  break 
and  result  in  ulceration.  Ixodes  or  peculiar  periosteal,  swellings  occurring 
in  syphilis  are  collections  of  proliferating  syphilitic  cells^granuloma. 

The  syphilitic  roseola  has  not  been  mentioned  in  connection  with  the 
syphilitic  cell-proliferation  because  it  is  an  exception  to  the  rule.  It  is 
due,  not  to  a  localized  accumulation  of  cells,  but  to  vaso-dilation  and  stasis, 
with  resultant  transudation  and  liberation  of  blood-pigment.  This  condi- 
tion of  vascular  perturbation  is  probably  due  to  the  action  of  syphilitic 
toxins — elaborated  by  tlie  micro-organism  of  syphilis — upon  the  sympa- 
thetic nervous  system.  Otis  would  undoubtedly  have  advanced  this  ex- 
planation rather  than  that  of  the  action  of  the  syphilized  cell  upon  the 
sympathetic,  if  our  knowledge  of  toxins  had  been  developed  at  the  period 
at  which  he  presented  his  views.  In  any  event,  the  cell  may  be  the  carrier 
of  the  toxins. 

What  has  been  said  serves  to  demonstrate,  in  a  general  way,  the  patho- 
logic importance  of  studying  the  syphilitic  cell,  by  following  it  in  its  tour 


352  SYPHILIS. 

of  mischief  and  noting  briefly  its  results.  As  already  stated,  this  cell  is  not 
only  important  as  regards  the  pathology  of  syphilis,  but  a  knowledge  of  its 
properties  and  actions  is  absolutely  indispensable  to  the  intelligent  applica- 
tion of  remedies  to  the  cure  of  the  disease.  The  author  will  premise,  with 
Otis,^  that:— 

The  natural  course  of  the  syphilitic  cell  is  to  accumulate  in  and  obstruct 
various  tissues,  thereby  forming  neoplastic  masses  very  similar  in  structure  to  in- 
flammatory neoplasia,  and  finally  to  undergo  retrograde  metamorphosis  and  elimi- 
nation, ichich  result  eventually  in  the  spontaneous  cure  of  the  disease. 

The  danger  of  permanent  injury  to  the  tissues  in  syphilis  is  directly 
proportionate  to  the  amount  of  the  accumulated  cells  and  the  length  of  time 
they  remain  in  contact  with  the  normal  tissues,  thereby  producing  secondary 
changes  in  their  structure.  Understanding  these  facts,  and  with  an  eye  to 
the  probable  germ  origin  of  the  disease,  we  most  naturally  seek  for  reme- 
dies the  administration  of  which  tends  (1)  to  destroy  or  inhibit  the  germ- 
infection;  (2)  to  eliminate  and  remove  the  effects  of  syphilitic  toxins;  (3) 
to  remove  new  formations  and  cell-accumulations,  by  favoring  or  directly 
inducing  retrograde  metamorphosis  in,  and  elimination  of,  such  morbid 
material.  These  remedies  will  receive  attention  later  on,  as  at  this  jDoint 
the  author  desires  merely  to  emphasize  the  importance  of  an  accurate  knowl- 
edge of  the  pathology  of  syphilis  in  explaining  the  rationale  of  their  action. 
The  student  will  readily  appreciate  the  fact  that  a  careful  study  of  the  char- 
acteristic cell-deposit  which  constitutes  the  basis  of  all  syphilitic  processes 
will  enable  him  to  comprehend  the  principal  manifestations  of  the  disease. 

The  manner  in  which  syphilitic  infection  brings  about  the  various 
changes  characteristic  of  the  disease  will  now  be  considered.  As  we  have 
seen,  the  first  manifestation  of  syphilis  is  a  peculiar  lesion  characterized  by 
induration.  This  is  due  to  a  localized  accumulation  of  cells  that  are  in- 
filtrated in  the  meshes  of  the  connective  tissue  and  tunica  adventitia  of  the 
blood-vessels,  forming  a  circumscribed  mass.  The  cells  vary  somewhat  in 
their  general  characteristics,  those  in  the  coats  of  the  vessels  being  either 
round,  spindle-shaped,  or  branched,  but  the  bulk  of  the  mass  consisting  of 
the  characteristic  round,  multinucleated  granular  cell,  already  presented  as 
an  infected  and  transformed  leucocyte.-  These  changes  are  very  siinilar  to 
those  seen  in  simple  dermatitis,  excepting  that  there  is  no  exudate,  the  in- 
duration being  consequently  dry  and  hard.  This  absence  of  fluid  is  due  to 
the  thickened  walls  and  contracted  lumen  of  the  vessels,  that  render  it  diffi- 
cult for  the  serum  to  exude  from  them.  For  the  same  reason,  there  is  anemia 
and  innutrition  of  the  neoplasm.^ 


^Otis:  "Physiology  and  Pathology  of  Syphilis."  With  regard  to  the  local 
changes,  Otis  does  not  differ  essentially  from  the  generally-accepted  views  of  syphi- 
litic neoplasm  or  granuloma. 

^  Tide  Besiadecki. 


LYMPHATIC    CHANGES.  353 

The  small  blood-vessels  throughout  the  body  are  surrounded  by  peri- 
vascular lymijli-simces — it  is  even  claimed  that  the  tunica  adventitia  of  the 
smaller  vessels  is  really  a  part  of  the  lymphatic  system.  The  intimate  asso- 
ciation of  the  blood  and  lymphatic  vessels  is  thus  readily  imderstood.  There 
is  a  constant  current  from  the  tissues  to  the  lymphatics,  and  it  is  very  evi- 
dent that  after  a  time  the  morbid  cells  about  the  neoplasm — -or  the  micro- 
organisms they  contain — must  necessarily,  as  they  extend,  enter  the  lym- 
phatic circulation.  This  may  explain  the  circumscription  of  the  induration, 
the  cells,  after  a  certain  time,  being  removed  as  fast  as  formed,  thus  limiting 
their  local  development. 

It  will  now  be  assumed  that  the  first  manifestations  of  S3fphilis  are 
2Durely  local  pathologically — as  they  certainly  are  clinically — and  an  attempt 
will  be  made  to  give  a  logical  explanation  of  them  along  the  lines  laid  down 
by  Otis,  with  certain  modifications  that  suggest  themselves  to  the  author  as 
modernizing  his  theory. 

Evolution  of  Primary  Lympliitis  and  Adenopathy. — Within  a  few  days 
after  the  development  of  the  initial  induration  of  syphilis,  or  chancre,  the 
lymphatic  vessels  leading  from  the  infected  surface  begin  to  enlarge  and 
become  hardened,  feeling  often  like  pieces  of  pencil  or  wire  under  the 
skin.  This  is  due  to  a  low  grade  of  inflammatory  change,  associated  with 
localized  cell-proliferation.  It  may  seem  strange  that  this  alteration  in  the 
lymphatics  does  not  occur  immediately  after  the  appearance  of  the  chancre, 
instead  of  after  an  interval  of  some  days,  but  this  is  probably  explained  b}^ 
the  fact  that  the  cell-accumulation  constituting  the  chancre  must  extend 
until  a  l3miphatic  vessel  of  some  size  is  reached  before  the  cells  can  enter 
the  lymphatic  current,  the  absorptive  power  of  the  smaller  lymphatics  being 
annulled  by  pressure  and  local  irritation.  A  strong  argument  in  favor  of 
this  view  is  the  fact  that  the  period  of  incubation  is  shortest,  and  the  chan- 
cre smallest,  in  those  parts  most  richly  supplied  with  lymphatics.  There  is 
also  less  connective-tissue  proliferation  in  such  localities.  An  example  of 
this  is  chancre  developed  beside  the  frenum  preputii.  The  changes  in  the 
lymphatic  vessels  gradually  extend  along  their  course,  the  infection-bear- 
ing cells,  or  perhaps  free  micro-organisms,  meanwhile  traveling  slowly  on 
in  the  lymph-current,  and  finally  reaching  the  lymphatic  glands.  Enlarge- 
ment of  the  glands — primary  adenopathy — now  occurs,  those  in  closest 
relation  to  the  primary  sore  being  first  to  enlarge,  but  general  syphilitic 
adenopathy  eventually  occurring,  and  each  gland,  however  small,  becoming 
consequently  a  depot  for  the  production,  storing  up,  and  finally  the  dis- 
tribution of  the  infection.  Each  lymphatic  gland,  as  the  proliferation  of 
infected  cells  goes  on  in  its  substance,  becomes  hard  and  woody  to  the  touch, 
being  nothing  more  nor  less  than  a  neoplastic  growth  precisely  identic 
Avith  the  chancre  itself,  and  presenting  the  same  microscopic  characters. 
The  changes  at  the  site  of  infection,  and  in  the  lymphatic  glands  first  in- 
volved, have  been  most  appropriately  termed  the  "initiatory  period"   of 


354  SYPHILIS. 

syphilis,  a  much  more  satisfactory  nomenclature  than  "primarj^  syphilis." 
Xo  eyidenees  of  hlood-infection  have  become  manifest  as  yet,  all  the  changes 
being  aj)parently  local.  The  infection  and  cell-migration  having  been  traced 
to  the  lymphatic  glands,  their  further  consideration  will  be  deferred  until 
a  little  more  attention  has  been  devoted  to  the  initial  lesion  and  other  im- 
portant points  in  the  clinical  study  of  early  syphilis. 

Yakieties  of  Ixdueatiox. — The  initial  induration — initial  sclerosis 
— may  present  itself  under  several  different  forms,  a  study  of  which  is  very 
essential. 

1.  The  first  form  is  what  is  termed  the  parchment  induration.  This 
usually  underlies  ulceration,  and  may  escape  notice  altogether  unless  care- 
fully sought  for  by  pinching  up  the  lesion  with  the  thumb  and  finger  in 
such  a  manner  as  to  press  lightly  upon  its  edges  without  bending  it.  This 
is  the  commonest  form,  according  to  some  authorities,  and  is  certainly  so  in 
hospital  practice.  In  private  practice,  however,  examples  of  the  Hunterian 
chancre,  or  other  marked  forms,  are  more  frequent  in  the  author's  experi- 
ence. 

2.  There  is  a  variety  of  the  parchment  induration  sometimes  seen  that 
is  especially  apt  to  escape  attention,  so  insignificant  does  it  seem.  It  con- 
sists in  a  very  superficial  cell-infiltration,  presenting  a  very  slight  induration 
when  lightly  pressed  upon.  In  appearance  it  is  a  slightly-brownish  patch 
covered  by  very  fine  scales,  not  unlike  a  minute  patch  of  psoriasis.  This 
superficial  induration  is  called  by  Otis  the  "dry  scaling  patch."  The  author 
would  suggest  as  a  better  term  "squamous  induration." 

3.  The  induration  may  be  somewhat  like  a  split  pea  beneath  the  skin, 
its  convex  surface  being  capped  by  ulceration.  This  induration  is  plainly 
marked  and  freely  movable,  with  a  feeling  like  wood  or  bone,  or  perhaps 
more  nearly  like  cartilage. 

4.  The  induration  may  be  quite  extensive  and  extend  beyond  the 
bounds  of  the  ulceration,  very  often  attaining  the  dimensions  of  a  chestnut 
or  almond.  There  may  or  may  not  be  ulceration.  ^Mien  an  induration  of 
this  description  is  ulcerated,  its  convexity  is  sometimes  capped  with  a  fun- 
nel-shaped ulcer,  the  whole  constituting  the  so-called  Hunterian  chancre. 
In  many  cases  there  is  merely  a  hard  purplish  lump  with  no  ulceration,  or 
at  most  a  very  superficial  erosion  capping  the  induration.  In  many  cases 
the  induration  is  irregular,  sometimes  presenting  several  distinct  tumors, 

.  or  united  by  areas  of  less  marked  induration,  giving,  in  the  case  of  the  penis, 
a  "choked"  appearance  to  the  organ. 

5.  A  very  superficial  infiltration  may  underlie  a  pseudomembrane  of 
greater  or  less  dimensions:    "diphtheritic  chancre." 

Loss  OF  Tissue  ix  Chaxcee. — The  occurrence  of  ulceration  in  chan- 
cre is  quite  important,  and,  aside  from  the  various  sources  of  irritation  that 
may  act  as  exciting  causes,  is  explicable  by  the  histologic  characters  of  the 
lesion.     As  alreadv  noted,  the  chancre  consists  of  localized  cell-accumula- 


I 


CHAEACTEEISTICS    OF    THE    IXITIAL    IXDUEATION.  355 

tion  that  not  only  presses  upon  the  capillaries^,  but  actually  invades  their 
walls,  thus  causing  a  diminution  of  blood-supply  and  relatiTe  anemia  and 
innutrition  of  the  neoplasm  and  the  tissues  involved  by  it.  This  innutrition 
gives  rise  to  molecular  disintegration  of  the  superficial  layers  of  the  lesion, 
which  break  down  and  form  an  ulcerated  surface.  This  process  is  termed 
by  Besiadecki,  "anemia  of  tissue,"  and  by  Virchow,  "necrobiosis."  The  se- 
cretion of  this  ulcer  is  scanty  when  unirritated,  for  the  same  reason  given 
for  the  hardness  and  dryness  of  the  induration,  viz.:  absence  of  serous  ef- 
fusion. It  contains,  however,  the  infectious  principle  of  syphilis — the  syph- 
ilitic microbe  and  its  carrier,  the  germinal  cell— and  is  highly  contagious. 

Extent  of  Indukatiox. — The  induration  of  chancre  is  variable  in  its 
extent,  according  to  the  tissues  in  which  it  is.  situated,  and  within  certain 
limits  is  proportionate  to  the  extent  of  surface  primarily  infected, — e.g., 
when  an  extensive  cut  or  abrasion  is  inoculated  with  the  S3'philitic  infec- 
tion the  resulting  chancre  is  likely  to  assume  the  size  and  conformation  of 
the  traumatic  lesion.  Chancres  of  the  nipple,  lips,  skin,  and  behind  the 
corona  glandis  are  likely  to  be  extensiA'ely  indurated.  Bernard  finds  in- 
duration most  marked  upon  the  inner  surface  of  the  prepuce  and  in  the  fossa 
glandis,  and  nearl}^,  if  not  always,  absent  upon  the  body  of  the  organ.  In 
this  latter  statement  the  author  does  not  quite  agree,  for,  although  true  in 
a  large  proportion  of  cases,  there  still  remains  a  certain  number  in  which 
the  induration  is  not  only  present,  but  quite  plainly  marked  upon  the  body 
of  the  penis.  It  is  usually,  however,  quite  dry  and  often  scaly, -resem- 
bling a  patch  of  psoriasis — the  squamous  induration.  Bernard  also  states 
that  in  females  induration  is  most  marked  upon  the  nymplue.  In  a  general 
way,  it  may  be  accepted  that  it  is  most  pronounced  when  situated  upon 
mucous  membranes.  In  such  spongy  tissues  as  the  glans  penis  the  indura- 
tion is  apt  to  be  very  slight.  The  sparsity  of  connective  tissue  beneath  the 
mucous  membrane  of  this  structure,  and  the  extreme  tenuity  of  the  mucous 
membrane  itself,  will  perhaps  serve  to  explain  the  latter  fact.  The  in- 
fection of  syphilis  is  pre-eminently  a  promoter  of  connective-tissue  hyper- 
plasia, which  explains  the  slight  amount  of  proliferated  cells  in  locations 
sparsely  supplied  with  connective  tissue. 

Atypic  Indltratiox. — In  quite  rare  cases  of  chancre,  or  apparently 
simple  lesions  followed  by  constitutional  syphilis,  induration  appears  to  be 
entirely  absent.  This  is  perhaps  due  to  the  fact  that  it  has  been  overlooked 
through  carelessness,  or  co-existence  with  chancroid,  or  it  is  so  slight  that  it 
escapes  attention.  After  a  chancre  becomes  phagedenic,  induration  shortly 
disappears. 

It  is  a  peculiar,  and  at  the  same  time  unfortunate,  fact  that  typically- 
indurated  chancre  is  a  rare  thing  in  women.  Yenereal  sores  appear  and  dis- 
appear, and  contagion  is  spread  about  promiscuously  in  many  instances, 
while  the  patient  is  entirely  unconscious  of  her  trouble.  Seldom,  indeed, 
does  the  physician  have  the  opportunity  of  seeing  a  typic  sore  in  a  woman. 


356  SYPHILIS. 

and  the  author's  experience  has  taught  him  that  most  cases  of  syphilis  in 
women  follow  very  insignificant-looking  lesions.  We  meet  with  a  relatively 
large  proportion  of  cases  in  which  the  patient  is  unaware  of  her  disease  until 
secondary  symptoms  prompt  her  to  seek  advice.  If,  at  this  time,  the  focus 
of  infection  be  sought  for,  rarely,  indeed,  can  it  be  found.  While  com- 
mitted to  the  view  that  in  all  cases  of  syphilis  induration  of  greater  or  less 
degree  must  necessarily  have  existed  at  the  atrium  of  infection, — i.e.,  at  a 
point  corresponding  to  the  site  of  inoculation, — it  is  obvious,  from  what  has 
just  been  stated  in  regard  to  chancre  in  women,  that  the  original  site  of 
infection  is  not  always  easy  to  determine.  The  following  case  from  private 
practice  is  a  pertinent  illustration  of  this  fact: — 

Case. — The  author  ^vas  consulted  by  a  young  man  in  regard  to  a  sore  upon  his 
penis  that  proved  to  be  a  hard  chancre,  and  was  followed  by  secondary  syphilis.  After 
the  local  lesion  had  disappeared,  at  a  time  when  he  considered  himself  free  from  lesions 
and  nothing  could  be  detected  upon  either  his  penis  or  elsewhere,  he  resumed  inter- 
course with  a  former  mistress  who  was  perfectly  healthy.  Within  about  eight  or  ten 
weeks  after  this  the  young  woman  presented  herself  with  a  characteristic  roseola  and 
sore  throat.  The  most  careful  examination  and  inquiry  failed  to  discover  the 
slightest  sign  or  history  of  a  primary  sore.  In  the  progress  of  the  case  the  woman 
went  through  a  very  severe  and  obstinate  course  of  the  disease.  About  four  or 
five  months  after  contracting  her  disease  she  brought  her  only  child,  a  girl  of  seven, 
to  the  author  for  examination.  The  skin  of  the  child  was  thickly  studded  with  a 
maculo-papular  eruption  of  a  very  suspicious  appearance.  Careful  inquiry  failed  to 
elicit  any  history  of  a  primary  sore,  and  a  most  thorough  examination  gave  a  negative 
result.  The  author  was  in  doubt  about  the  diagnosis,  although  the  lymphatic  glands 
were  moderately  enlarged,  until  a  characteristic  mucous  patch  appeared  upon  the 
tongue.  A  course  of  gray  powder  cleared  away  the  eruption  very  speedily,  confirming 
the  diagnosis. 

CouESE  OF  THE  Indukation. — In  simple  chancre  the  induration  most 
generally  precedes  the  ulceration,  but  often  follows  it,  coming  on  during  the 
first  week.  The  primary  occurrence  of  ulceration  is  probably  due  to  some 
local  irritant  acting  chemically,  or  chancroidic  or  pus-infection  occurring 
simultaneously  with  the  syphilitic  infection.  This  is  the  invariable  course  of 
mixed  sores,  and  it.  is  highly  probable  that  the  majority  of  cases  in  which 
induration  follows,  instead  of  preceding,  ulceration  are  primarily  either 
chancroid,  herpes,  or  simple  ulceration  from  pus-microbes.  The  author  is 
inclined  to  believe  that  this  is  alwa^^s  the  case,  and  we  may  accept  the  rule 
that  syphilitic  ulceration  is  always  due  to  ''necrobiosis,"  or  "anemia  of  tissue," 
unless  there  exists  some  source  of  irritation,  simple  or  specific.  This  is  em- 
phasized more  particularly  because  this  method  of  ulceration  is  the  t^^pe  of 
tissue-destruction  seen  throughout  the  entire  course  of  syphilis.  It  should 
be  remembered  that  ulceration  of  syphilitic  lesions  in  general  is  primarily, 
in  certain  instances,  the  result  of  simple  innutrition  from  pressure  and  tis- 
sue-obstruction, infection  with  pus-microbes  being  afterward  superadded. 
It  matters  not  whether  the  molecular  disintegration  produced  by  syphilitic 


INOCULABILITY    OF    CHANCRE.  357 

neoplasia,  or  occurring  within  them,  results  in  an  open  lesion,  as  an  ulcer, 
or  occurs  in  the  form  of  a  softening  node  or  pustule,  the  process  is  the  same 
throughout,  being  modified  only  by  the  presence  or  absence  of  secondary 
mixed  infection.  If  this  pathologic  generality  be  remembered,  the  study  of 
syphilitic  phenomena  will  be  greatly  simplified. 

The  induration  of  chancre  may  be  transitory,  and,  as  already  indicated, 
may  disappear  so  rapidly  as  to  be  overlooked.  Cases  have  been  observed 
in  which  it  lasted  only  ten  or  twelve  days,  but  such  cases  are  exceptional, 
the  ordinary  duration  being  from  one  to  three  months,  in  rare  cases  lasting 
for  some  years.  The  author  has  met  with  several  cases  of  long-persistent 
chancrous  induration.  In  several  instances  excision  became  necessary,  the 
induration  in  one  case  persisting  for  two  years.  In  such  cases  intrinsic 
severity  of  the  general  infection  is  to  be  inferred. 

Seceetion  of  Chancee. — The  secretion  of  syphilitic  chancre  is  very 
scanty  and  sero-purulent  for  reasons  already  given,  and  retains  these  char- 
acters throughout  unless  the  sore  becomes  inflamed,  in  which  case  it  be- 
comes profuse  and  purulent,  and  perhaps  bloody.  Some  cases  of  chancre 
appear  to  exhibit  a  marked  tendency  to  bleed.  A  number  of  cases  have  oc- 
curred in  the  author's  practice  in  which  this  symptom  was  quite  persistent 
and  recurred  upon  the  slightest  manipulation  of  the  sore — the  so-called 
"hemorrhagic  chancre." 

CiCATEix  OF  Chancee. — The  scar  left  by  chancre  depends  upon  the 
depth  of  the  ulceration.  In  many  cases  nothing  is  left  but  a  livid  or  "ham- 
colored"  spot,  that  perhaps  becomes  of  a  coppery  hue  later  on  and  finally 
fades  completely.  When  complicated  by  other  kinds  of  infection,  chancre 
leaves  a  scar  proportionate  to  the  extent  of  destruction  by  the  complicating 
process. 

Inoculability  OF  Chancee. — -The  fact  that  syphilis  is  not  autoin- 
oculable  has  already  been  alluded  to,  this  being  a  very  important  point  in 
the  differentiation  of  chancre  and  chancroid.  Many  attempts  have  been 
made  with  syphilitic  secretions,  and  especially  the  secretion  of  the  chan- 
crous ulcer,  but  autoinoculation  has  thus  far  been  found  impossible,  as  a 
rule.  When  chancre  is  inflamed  and  secreting  profusely, — containing  toxins 
and  pyogenic  microbes — its  secretion  will  produce  a  pustule  if  autoinocu- 
lated,  acting  like  any  other  irritant.  This  pustule  may  be  followed  by  ulcer- 
ation, but  never  by  hard  chancre.  When  the  sore  is  mixed,  autoinoculation 
is,  of  course,  feasible. 

Van  Boosbroeck  long  ago  claimed  that  all  pus  is  more  or  less  con- 
tagious. While  not  an  invariable  result,  it  is  undoubtedly  true  that  inocu- 
lated pus  will  often  produce  more  or  less  inflammation  in  tissues  previously 
sound.  This  is  more  marked  and  more  likely  to  be  followed  by  suppuration 
in  some  persons  than  in  others.  The  explanation  of  pus-contagion  is  simple 
enough  in  these  days  of  pus-microbes. 

It  has  occurred  to  the  author  as  probable  that  in  very  unclean  persons 


358  SYPHILIS. 

the  secretion  of  chancre  may  evolve  a  germ-infection  that  is,  in  effect, 
identic  with  chancroid,  and  it  seems  plausible  enough  that  some  of  the. 
cases  of  "mixed  sore"  are  cases  that  have  undergone  a  marked  change — i.e., 
to  a  chancroidic  character — as  a  result  of  the  local  circumstances  of  heat, 
moisture,  filth,  and  irritation. 

It  is  questionable  whether,  if  blood  be  drawn  from  an  initial  lesion  be- 
fore ulceration  occurs, — i.e.,  early  enough  in  the  course  of  chancre, — it  may 
not  be  capable  of  inoculating  the  individual  possessing  the  lesion;  indeed, 
such  an  occurrence  has  been  reported.  This  harmonizes  Avith  the  theory 
that  syphilis  is  primarily  local.  The  following  case  bears  directly  upon  this 
point : — • 

Case. — A  large  indurated  penile  chancre  with  slight  attendant  ulceration  was  ex- 
cised. The  precaution  M-as  taken  of  waiting  until  the  process  was  apparently  station- 
ary and  the  chancre  fully  developed.  The  ulcer  was  first  cauterized  to  prevent  con- 
tamination of  the  wound  by  its  secretion,  after  which  the  indurated  tissue  was 
thoroughly  excised,  the  incisions  being  made  well  beyond  the  borders  of  the  diseased 
tissues.  An  irregular  wound  was  left  that  was  closed  with  several  catgut  sutures. 
On  the  second  day  the  wound  had  united  and  everything  looked  well;  but  on  the 
fourth  day  induration  of  the  edges  of  the  wound  began,  and  in  a  few  days  had 
involved  their  entire  extent  and  the  surrounding  tissues  for  some  little  distance, 
finally  attaining  the  size  of  an  almond,  being  at  least  double  the  size  of  the  chancre 
excised. 

The  recurrence  of  induration  in  the  foregoing  case  is  certainly  sug- 
gestive. x\ll  the  indurated  tissue  had  been  removed,  and  if  constitutional 
syphilis  already  existed,  no  infection  of  the  cut  surfaces  should  have  oc- 
curred. As  there  seems  to  be  no  other  explanation,  it  would  appear  that 
the  infection  took  place  through  the  medium  of  the  blood  that  escaped  from 
the  chancre.  It  is  certainly  peculiar  that  the  resulting  chancre  should  have 
been  proportionate  in  extent  to  the  cut  surfaces  and  of  similar  shape.  The 
speedy  recurrence  of  the  induration  is  noteworthy. 

Wallace  cites  a  case  in  which  he  succeeded  in  inoculating  a  man  Avith 
"syphilitic  virus,"  producing  a  true  chancre,  when  the  patient  was  already 
in  the  eruptive  stage  of  the  disease.  Fournier  estimates  that  about  2  per 
cent,  of  autoinoculations  of  true  chancre  are  successful,  but  presumably 
only  when  some  inflammatory  change  in  the  sore  exists.  The  author  has 
already  expressed  the  belief  that  a  greater  proportion  might  be  successful 
if  performed  sufficiently  early  in  the  course  of  the  disease.  The  practical 
rule,  however,  is  that  autoinoculation  of  true  chancre  is  not  feasible, 
although  it  may  possibly  succeed  if  done  very  early. 

When  the  syphilitic  infection  is  inoculated  upon  a  number  of  raAv  sur- 
faces simultaneously,  or  after  a  few  days'  interval,  chancre  usually  appears 
at  each  infected  point  at  about  the  same  time.  This  is  a  valuable  point  in 
differential  diagnosis,  for  chancre,  unlike  chancroid,  is  usually  multiple 
from  the  beginning,  if  at  all,  while  chancroid  may  become  multiple  by  auto- 
inoculation.   A  fcAv  apparent  exceptions  to  this  rule  have  been  noted. 


TYPIC    COUESE    OF    LOCAL    SYPHILIS.  359 

In  the  stage  of  sequels— i.e.,  the  so-called  "tertiary  period" — the  secre- 
tion of  chancre  from  another  person  may  be  inoculated,  although  rarely. 
Although  the  disease  proper  has  disappeared,  the  patient  is  still  relatively 
immune. 

Typic  Couese  of  Local  Syphilis  feom  Dieect  Inoculation. — The 
course  of  syphilis  following  heteroinoculation  is  interesting.  When  any 
secretion  containing  syphilitic  infection,  such  as  discharge  from  a  syphilitic 
chancre  or  mucous  patch,  or  blood  from  a  syphilitic  subject,  is  inoculated 
upon  a  healthy  individual,  there  may  be  a  small  pustule  following,  as  from 
the  prick  of  a  septic  lancet,  due  to  pus-organisms;  but  this  lasts  only  a  few 
days,  and  is  generally  absent,  there  being  nothing  to  indicate  the  site  of 
inoculation,  unless  perhaps  a  speck  of  dried  blood,  until  after  a  period  of 
from  ten  to  forty  days,  when  an  indurated  papule  appears.  This  becomes 
"ulcerated"  most  likely,  but  may  not  do  so;  the  neighboring  lymphatics  be- 
come enlarged,  and  general  syphilis  follows.  In  vaccinal  syphilis — i.e., 
syphilis  acquired  accidentally  in  the  operation  of  vaccination — a  somewhat 
different  course  is  followed.  The  incubation  period  of  vaccinia  expires  first, 
the  characteristic  vesicle  appearing  and  running  its  usual  course.  After 
a  time,  however,  the  vaccine-vesicle  becomes  an  ecthymic  ulcer  with  an  in- 
durated base,  or  induration  appears  and  runs  its  course  without  ulceration. 
When  a  subject  already  syphilitic  is  vaccinated,  we  are  likely  to  have  a 
characteristic  secondary  syphilitic  ulcer  resulting  after  the  typic  vaccinal 
vesicles  have  first  formed.  Such  an  instance  recently  occurred  in  one  of  the 
author's  patients,  although  under  the  influence  of  mercury  at  the  time.  A 
very  important  source  of  error  with  regard  to  vaccinal  syphilis  and  one  that 
should  always  be  borne  in  mind,  is  that  the  local  and  constitutional  dis- 
turbance produced  by  vaccinia  is  liable  to  develop  latent  S5^philis,  whether 
hereditary  or  acquired,  in  which  event  the  vaccinator  will  probably  get  the 
credit  of  having  inoculated  the  disease.  In  such  cases  a  more  or  less  general 
eruption  Avill  usually  be  observed,  commencing  in  the  vicinity  of  the  sore, 
instead  of  the  typic  period  of  incubation  followed  by  typic  induration,  and 
after  a  variable  time,  by  glandular  enlargement  and  general  syphilis.  The 
following  case  reported  by  J.  S.  Prettyman  is  an  excellent  illustration  of 
the  course  of  vaccinal  syphilis,  but  contains  an  unfortunate  source  of  fallacy 
in  the  fact  that  the  changes  in  the  vaccinal  sore  are  not  described.  Without 
typic  induration  such  cases  are  open  to  question.  In  this  instance  the  omis- 
sion was  evidently  unavoidable: — ■ 

Case. — Mr.  N.  T.,  aged  30,  has  been  married  nine  years.  His  wife  is  healthy, 
has  never  aborted,  and  is  entirely  free  from  skin  disease.  They  have  two  robust 
children,  aged  6  and  8,  who  have  always  been  well,  but  are  subject  to  a  "breaking 
out."  Ten  years  ago  the  patient  vaccinated  himself  directly  from  the  arm  of  another, 
who,  it  was  said,  had  been  cured  of  a  "bad  disorder."  In  about  two  weeks  an  erup- 
tion appeared  over  the  entire  body  and  continued  three  months,  disappearing  and 
reappearing  several  times  since.     From  time  to  time  lumps  have  been  noticed  over 


360  SYPHILIS. 

various  parts  of  the  body.  He  has  never  had  ulcers  in  the  throat,  but  the  glands 
have  been  enlarged,  and  several  times  chronic  abscesses  have  formed.  He  received 
no  treatment  except  such  remedies  as  he  would  apply  locally.  He  presented  himself 
with  nodes,  bullous  sj^hiloderm,  and  ulcerations  upon  the  neck,  arms,  back,  and 
legs.  He  denied  all  possibility  of  contagion  from  any  other  source,  and  affirmed  that 
previous  to  the  vaccination  and  appearance  of  the  eruption  he  had  not  even  once 
indulged  in  sexual  intercourse. 

It  is  self-evident  that  the  accuracy  of  the  diagnosis  in  the  foregoing 
case  depends  upon  the  patient's  Te^acit5^ 

CoMPAEATivE  Feequexct  OF  Chaxcre  axd  Chaxceoid. — The  rela- 
tive frequency  of  chancre  and  chancroid  is  variously  estimated  hy  different 
observers.  Thus,  Fournier  finds  in  his  private  practice  that  the  frequency 
of  chancre  as  compared  with  chancroid  is  about  three  to  one.  The  statistics 
of  ten  years  at  one  of  the  large  Parisian  hospitals  show  that  chancroid  com- 
prised about  80  per  cent,  of  sores.  From  clinical  experience  the  author  is 
inclined  to  believe  that  these  estimates  are  fair  criterions  of  the  relative  fre- 
quency of  the  two  varieties  of  genital  sore  as  seen  in  both  private  and  hos- 
pital practice.  It  must  be  remembered,  however,  that  in  hospital  practice 
patients  with  atypic,  and  possibly  mixed,  sores  are  often  lost  sight  of  after 
they  leave  the  hospital.  Doubtless  many  of  these  afterward  develop  syph- 
ilis, thus  cutting  down  the  percentage  of  simple  chancroid. 

IxFECTious  Seceetioxs  IX'  Syphilis. — The  consideration  of  the  vari- 
ous secretions,  physiologic  and  pathologic,  that  are  capable  of  transmitting 
syphilis  is  very  important.  They  have  been  exhaustively  studied  by  different 
observers,  among  the  most  thorough  of  which  have  been  Bassereau,  Diday, 
EoUet,  Fournier,  and  Clerc.  These  investigators  have  arrived  at  practically 
the  same  conclusions.  Inoculations  with  the  secretions  of  chancre,  mucous 
patches — in  short,  all  secondary  cutaneous  or  mucous  lesions  capable  of 
yielding  a  discharge,  and  of  syphilitic  blood  have  been  made  with  entire 
success.  Whether  the  blood  is  infectious  between  the  periods  of  active  mani- 
festations of  the  disease  has  not  been  determined  by  experiment,  but  from 
observations  made  upon  vaccinal  S3^philis  it  probably  is.  There  would  seem 
to  be  no  logical  reason  why  the  blood  should  not  be  infectious  at  this  time, 
inasmuch  as  each  successive  crop  of  lesions  is  not  due  to  a  new  development 
of  syphilitic  infection,  but  to  its  renewed  activity.  The  secretions  of  non- 
syphilitic  lesions  occurring  upon  a  syphilitic  are  not  inoculable  unless  mixed 
with  the  blood  of  the  syphilitic  subject:  e.g.,  the  secretions  of  gonorrhea 
and  chancroid  occurring  in  a  syphilitic  produce  only  gonorrhea  and  chan- 
croid unless  there  is  an  admixture  of  syphilitic  blood.  Diday  inoculated 
pus  from  acne  pustules  produced  by  potassic  iodid  on  a  syphilitic  subject, 
but  with  negative  results.  It  is  also  probably  true  that  vaccine-lymph  de- 
rived from  a  syphilitic  is  not  capable  of  producing  syphilis  unless  it  con- 
tains some  of  the  patient's  blood.  This,  however,  should  make  the  physician 
none  the  less  cautious,  for  it  is  very  easy  for  a  small  quantity  of  blood  to  be- 


IXFECTIOUS    SECEETIOXS    IN    SYPHILIS.  361 

come  mixed  with  the  Ijanph  and  remain  undetected.  '  The  vaccine-scab 
from  a  syphilitic  patient  is  always  dangerous,  as  it  invariably  contains  a 
certain  proportion  of  dried  blood  in  its  composition.  This  view  has  been 
disputed,  and  in  a  most  heroic  manner,  by  an  English  physician,  whose  ex- 
periments, however,  simply  serve  to  confirm  the  opinion  already  expressed, 
inasmuch  as  it  seems  evident  that  in  the  last  and  successful  inoculation  the 
experimenter  must  have  used  lymph  mixed  with  a  minute  quantity  of  blood. 
If  this  were  not  the  case,  how  can  the  failure  of  the  first  three  experiments 
be  explained?     The  experiments  were  as  follow: — 

With  a  desire  to  settle  for  himself  the  vexed  question,  Avhether  vaccine-lymph 
taken  from  a  syphilitic  person,  if  unmixed  with  the  blood  of  the  vaccinifer,  does 
not  contain  syphilitic  virus,  and  is  incapable  of  imparting  syphilis  by  its  inoculation. 
Dr.  Cory  made  at  intervals  four  separate  experiments  upon  himself  with  lymph 
derived  from  obviously-syphilitic  children.  The  last  experiment  was  successful,  and 
Dr.  Cory  had  to  endure  all  the  pains  and  penalties  of  syphilitic  inoculation.  The 
committee  appointed  to  investigate  Dr.  Cory's  experiments,  consisting  of  Drs.  Bris- 
towe,  Humphrey,  Ballard,  and  Mr.  Hutchinson,  report  that  it  is  possible  for  syphilis 
to  be  communicated  in  vaccination  from  a  vaccine-vesicle  on  a  syphilitic  person,  not- 
withstanding that  the  operation  be  performed  with  the  utmost  care  to  avoid  the 
admixture  of  blood.^ 

How  was  it  possible  for  the  committee  to  determine  absolutely  the  ab- 
sence of  blood?  There  is  no  account  of  a  careful  microscopic  test  having 
been  made. 

The  infection-bearing  element  of  syphilitic  blood  is  quite  likely  the 
white  corpuscles,  though  no  confirmatory  observations  have  been  made  upon 
this  point.  The  germs  may  exist  free  in  the  blood,  although  this  is  not 
probable. 

Inoculations  with  the  secretions  of  tertiary  lesions  and  with  blood  dur- 
ing the  tertiary  stage  of  syphilis  are  negative,  although  there  have  been 
apparent  exceptions  to  the  rule.  Bumstead  relates  a  case  of  inoculation  of 
a  surgeon's  finger  while  operating  upon  a  case  of  tertiary  necrosis  of  the 
skull.  The  author  will  also  cite  the  case  of  an  intimate  friend  who  in- 
oculated his  finger  in  operating  upon  a  rectal  fistula  in  a  patient  suffering 
from  tertiary  S3^philis.  In  due  time  a  chancre  appeared,  and  was  followed 
by  a  well-marked  development  of  secondary  manifestations.  The  gentleman 
finally  died  from  cerebral  syphilis. 

The  possibility  of  such  cases  as  those  from  whom  these  surgeons  con- 
tracted syphilis  being  illustrations  of  reinfection  of  subjects  suffering  from 
sequels  of  a  previous  attack  must  be  remembered,  otherwise  they  would  seem 
to  refute  the  physiologic  pathology.  It  is  also  to  be  considered  that  sub- 
sequent infection  from  some  other  source  might  have  occurred  in  the 
wounds  received  while  operating.  In  neither  of  the  cases  cited  were  the 
circumstances  such  as  to  preclude  the  possibility  of  such  infection. 


^  British  Medical  Journal,  May  13,  1884.     Dr.  Cory  has  at  least  enrolled  himself 
among  the  heroes  of  science. 


363  SYPHILIS. 

The  non-tran'smissibility  of  syphilis  during  the  tertiary  period  of  the 
disease  is  perhaps  the  strongest  evidence  in  favor  of  the  view  that  the  lesions 
of  this  stage  are  not  syphilitic  at  all,  but  are  simply  sequels.  Patients  suf- 
fering with  tertiary  manifestations  may  procreate  healthy  children,  although 
they  do  not  always  do  so.  In  many  cases  in  which  the  children  are  fairly 
healthy  and  cannot  justly  be  pronounced  syphilitic,  in  the  true  sense  of  the 
term,  there  will  be  found  some  remote  slight  manifestations  of  hereditary 
taint,  such  as  imperfect  or  irregular  development  of  the  teeth,  or  some  other 
of  the  various  manifestations  of  faulty  nutrition  that  we  are  wont  to.  accept 
as  evidences  of  a  strumous  diathesis.  Hutchinson's  experience  regarding 
the  efi&cacy  of  mercury  and  iodin  in  struma  probably  has  a  basis  quite  dif- 
ferent from  the  supposed  "antistrumous"  action  of  these  remedies.  The 
term  "attenuated  syphilis"  would  be  fitting  for  many  cases  of  so-called 
scrofula.  As  a  rule,  however,  we  may  accept  the  statement  that  tertiary 
syphilis  is  not  transmissible.  The  later  the  period  of  the  disease,  the  less 
the  liability  to  transmission,  and  it  is  also  probable  that  the  male  loses  the 
power  of  transmission  before  the  female;  this  is  certainly  true  of  hereditary 
transmission.  ISTone  of  the  physiologic  secretions,  such  as  mucus,  sweat, 
urine,  milk,  and  semen,  are  inoculable,  unless  they  contain  either  syphilitic 
blood  or  the  secretion  of  a  syphilitic  lesion.^  The  saliva,  so  often  the 
medium  of  contagion,  is  innocuous  unless  mucous  patches  or  other  lesions 
exist  in  the  mouth,  in  which  case  it  is  contagious  in  the  highest  degree. 
The  syphilitic  infection^be  it  cell  or  bacillus — must  be  present,  else  no 
secretion,  ph3^siologic  or  pathologic,  can  transmit  S3^philis.^ 


^  It  is  obvious  that  if  tlie  assertions  of  von  Xiessen  sliould  be  confirmed  this 
view  of  the  normal  secretions  of  syphilitic  subjects  will  be  refuted. 
"  A  proposition  that  is  self-evident. 


CHAPTER  XY. 

Methods  of  Acquieixg  Syphilis — Yaeieties  and  Teeatment  of 
Chaxcee — Peimaey  Syphilitic  Adenopathy. 

Methods  of  Acquieixg  Syphilis.— The  presence  of  the  probably 
germ-bearing  syphilitic  cell  or  free  bacilli  is  all  that  is  necessary  to  render 
any  secretion,  whether  physiologic  or  pathologic,  extremely  contagious,  and 
in  the  absence  of  this  infectious  cell — unless  the  germ  of  syphilis  exists  free 
in  the  secretions,  as  is  possible — no  contagion  can  occur.  Inasmuch  as  every 
morbid  secretion  produced  by  syphilitic  lesions  contains  the  syphilitic  in- 
fection, either  as  germ-infected  cells  or  free  bacilli,  and  the  lesions  of  syph- 
ilis are  many  and  various,  both  as  to  form  and  location,  the  opportunities 
for  transmitting  the  disease  and  the  methods  of  its  contraction  are  neces- 
sarily very  numerous.  The  contagiousness  of  the  blood  of  syphilitic  sub- 
jects during  the  active  period  of  the  disease  affords  an  additional  danger, 
as  there  are  several  ways  in  which  it  may  be  accidentally  inoculated. 

The  initial  lesion  of  syphilis  or  chancre  may  occur  upon  any  portion  of 
the  human  body,  the  only  essential  requisites  for  its  production  being  a 
secretion  containing  the  syjDhilitic  infection — i.e.,  cell  or  germ — and  a  sur- 
face, integumentary  or  mucous,  that  has  been  deprived  of  its  epithelium  and 
is  consequently  capable  of  absorption  of  extraneous  matter — i.e.,  an  atrium 
for  infection. 

In  every  method  of  transmission  of  syphilis,  with  the  exception  of  two, 
the  general  disease  is  always  preceded  by  chancre,  and  the  existence  of  the 
latter  may  be  inferred  whether  it  has  been  detected  or  not.  The  circum- 
stances in  which  a  chancre  is  never  present  are  (1)  the  infection  of  the 
child  w  utero  and  (3)  the  infection  of  the  mother  through  the  medium  of 
the  child,  the  latter  mode  of  transmission  being  still  a  subject  of  con- 
troversy. The  first  method  has  been  positively  demonstrated,  and  under 
either  circumstance  the  syphilitic  infection  enters  the  blood-current  di- 
rectly, and  not  through  the  medium  of  a  localized  process  of  infection  and 
proliferation  of  cells  followed  by  a  roundabout  tour  of  the  lymphatics. 
Probably  the  same  thing  would  occur  if  the  syjahilitic  secretion  or  blood 
were  injected  directly  into  a  large  blood-vessel.  Where  the  father  of  the 
child  is  syphilitic  and  the  mother  healthy,  the  child  may  escape  infection 
(1)  because  the  virus  is  temporarily  inactive  in  the  father — either  sponta- 
neously or  from  treatment;  (2)  he  may  have  no  infection-producing  lesions; 
(3)  the  mother  may  present  no  atrium  of  infection:  i.e.,  no  surface  capable 
of  inoculation;  or  (4)  the  father's  disease  may  be  so  far  advanced  in  the 
period  of  sequels  that  it  ceases  to  be  transmissible.  Excellent  authorities 
deny  that  the  child  can  be  infected  by  the  father  directly,  claiming  that 
such  infection  can  only  occur  through  the  medium  of  the  mother.     The 

(363) 


36i  SYPHILIS. 

author  was  formerly  inclined  to  believe  in  the  joossibilit}'  of  independent 
paternal  infection,  but  increasing  experience  has  led  to  the  opposite  view. 
This  much,  however,  is  certain,  viz.:  the  svphilitic  father  may  transmit  to 
the  child,  independently  of  maternal  infection,  various  dyscrasic  conditions 
characterized  by  nutritional  disturbances  that,  while  not  syphilitic  in  the 
literal  sense,  are  nevertheless  derivatives  of  syphilis.  .  It  is  highly  improb- 
able that  a  healthy  constitution  of  the  spermatozoa  can  exist  in  a  man  who 
is  jDrofoundh'  impressed  by  syphilis.  On  the  other  hand,  it  is  reasonable 
to  supi^ose  that  the  presence  of  active  syphilitic  infection  in  the  spermatozoa 
would  inevitably  prove  fatal  to  their  vitality,  and  that  consequently  the 
child  cannot  become  infected,  save  through  the  maternal  circulation.  AVhen 
the  mother  is  syphilitic  at  the  time  of  conception,  or  becomes  so  within 
seven  months  afterward,  the  child  is  invariably  infected,  unless  a  thorough 
course  of  treatment  is  instituted  during  the  period  of  pregnancy,  in  which 
case  it  may  possibly  escape — apparently,  at  least.  Oftentimes,  however,  the 
children  of  syphilitic  women  may  not  develop  the  disease  until  late  in  life, 
— syphilis  Jiereditaria  tarda, — thus  leading  to  the  supposition  that  they  have 
escaped  the  disease.  In  such  instances  the  disease  expends  its  violence  upon 
the  maternal  organism,  jDrobably  acting  in  a  manner  somewhat  analogous 
to  vaccinia.  AATien  the  mother  is  infected  after  the  seventh  month  of  preg- 
nanc}",  the  child  usually  escapes:  a  point  in  verification  of  the  views  of  the 
cell-pathology  of  syphilis  already  presented  and  which  will  shortly  be 
dilated  upon  more  fully. 

The  second  mode  of  contracting  syphilis  without  the  occurrence  of 
chancre  is  the  infection  of  the  mother  through  the  medium  of  the  child. 
This,  too,  is  denied  by  many  authorities,  even  among  those  who  accept  the 
direct  infection  of  the  child  through  the  father  independently  of  maternal 
infection.  That  the  author  does  not  accept  this  view  is  a  corollary  of  the 
opinion  already  expressed  regarding  immediate  infection  of  the  child  by 
the  father.  It  must  be  admitted,  however,  that  the  mother  often  apparently 
escapes  the  disease  entirely  or  has  very  mild  symptoms.  Granting  the  oc- 
currence of  independent  paternal  infection,  there  would  be  an  explanation 
of  this  fact  also  in  the  possible  analogy  of  fetal  infection  to  vaccination  first 
suggested  by  Hutchinson:  syphilis  in  the  mother  being  modified  greatly,  or 
entirely  prevented  by  the  infection  of  the  child  in  much  the  same  manner 
that  variola  is  modified  or  prevented  by  vaccination.  Theoretically  the  dis- 
ease expends  its  violence  upon  the  child  in  utero,  thus  rendering  the  subse- 
quent infection  of  the  mother  comparatively  mild,  if,  indeed,  it  occur  at  all. 
The  converse  of  this  hypothesis  seems,  however,  the  most  logical  view.  The 
fetus  in  idero  is  organically  an  integral  part  of  the  mother,  despite  the  ab- 
sence of  direct  nervous  and  vascular  connection.  The  mother  being  in- 
fected in  the  usual  manner,  the  disease  may  expend  its  violence  upon  the 
fetus  as  being  relatively  more  susceptible  than  the  maternal  organism  as  a 
whole.    The  child  is  consequently  profoundly  impressed,  while  the  mother's 


METHODS    OF   ACQUIEING    SYPHILIS.  365 

infection  is  overlooked  because  of  the  mildness  or  perhaps  entire  absence  of 
symptoms.  Argument  aside,  it  is  a  clinical  fact  that  infants  with  severe 
congenital  syphilis  are  often  born  of  mothers  who  are  apparently  healthy 
and  who  seemingly  remain  so.     The  following  is  a  case  in  point: — 

Case.- — A  young  man  under  the  author's  care  for  severe  secondary  syphilis  was 
engaged  to  a  healthy,  buxom  young  woman  of  German  extraction.  He  was  advised  to 
break  the  engagement,  which  he  did  Avithout  explanation.  It  subsequently  transpired, 
however,  that  the  young  woman  had  notions  of  her  own  regarding  the  matter,  and 
the  patient,  being  nothing  loath,  fell  in  with  her  ideas,  with  the  result  that  an  illicit 
intimacy  was  established.  The  young  woman  became  pregnant,  and  the  couple  were 
finally  married.  A  male  child  was  born  in  due  time,  that  was  apparently  healthy 
at  birth.  Within  three  weeks,  however,  the  characteristic  "snuffles,"  and  shortly 
afterward  a  marked  general  pafulo-bullous  syphiloderm  developed.  The  mother  has 
never  had,  so  far  as  can  be  determined,  the  slightest  manifestation  of  disease. 

It  has  been  stated  that  all  that  is  necesary  for  the  transmission  of  syph- 
ilis is  the  contact  of  a  germ-laden  secretion  from  a  syphilitic  lesion  with  an 
abraded  surface.  In  many  instances  of  infection  no  abrasion  is  perceptible, 
but  it  is  to  be  inferred  that  it  must  necessarily  have  existed,  inasmuch 
as  the  infection  cannot  be  absorbed  by  an  unbroken  epithelial  surface. 
AVhether  the  secretion  containing  the  syphilitic  virus  may  remain  in  con- 
tact Avith  a  sound  surface  of  mucous  membrane  until  maceration  and  re- 
moval of  its  epithelium  with  subsequent  absorption  occurs  is  not  positively 
known,  but  this  is  highly  probable  and  may  undoubtedly  occur  in  the  case 
of  secretion  from  a  mixed  sore,  which  is  usually  quite  corrosive. 

Modes  of  C ontagion.—Th.e  methods  of  contagion  in  syphilis  are  classi- 
fied as  mediate  and  immediate.  By  the  mediate  method  we  understand  the 
transmission  of  the  disease  through  the  medium  of  infected  drinking 
utensils,  tobacco-pipes,  towels,  etc.  Chancroid  is  very  rarely  transmitted  in 
this  wa}^,  but  syphilis  is  quite  often  so  transmitted  on  account  of  the  multi- 
plicity of  its  lesions,  that  are  sometimes  apparently  so  insignificant,  but  none 
the  less  infectious.  By  the  immediate  method  of  contagion  is  implied  the 
direct  contact  of  an  abraded  surface  in  a  healthy  person  with  a  secreting 
sj'philitic  lesion  or  with  syphilitic  blood  from  a  non-syphilitic  lesion  in  a 
syphilitic  subject.  The  type  of  this  mode  of  contagion  is,  of  course,  infec- 
tion during  sexual  intercourse,  but  the  disease  may  be  immediately  in- 
oculated in  many  other  ways;  quite  often  it  is  contracted  by  the  physician 
or  surgeon  in  operating  upon  or  examining  syphilitic  subjects.  Many 
prominent  obstetricians  anci  gynecologists  have  had  sad  experiences  in  this 
respect.  Chancre  is  sometimes  contracted  in  kissing,  a  small,  insignificant- 
looking — perhaps  unrecognized — mucous  patch  upon  the  lips  or  tongue  of 
the  diseased  person  inoculating  any  slight  fissure  or  abrasion  that  happens 
to  be  present  upon  the  lips  of  the  healthy  subject.  There  are  many  very 
sad  examples  of  this  mode  of  contagion.  The  author  has  had  a  large  num- 
ber of  such  cases  under  observation  in  private  practice.     Bulkley  has  col- 


366 


SYPHILIS. 


lected  a  surprisingiy  large  mass  of  clinical  examples  of  syphilis  in  the  inno- 
cent.^ Infants  may  contract  syphilitic  chancre  from  the  nipples  of  syph- 
ilitic nurses,  and,  on  the  other  hand,  a  healthy  nurse  may  contract  chancre 
of  the  nipple  from  a  syphiHtic  ijifant.  CoUes's  law,  so  called,  that  an 
hereditarily-syphilitic  infant  cannot  infect  its  mother,  depends  simply  upon 
the  fact  that  the  mother  already  has,  or  has  had,  syphilis.  As  already  sug- 
gested, the  possible  analogy  to  vaccinia  may  explain  it,  the  syphilization  of 
the  infant  having  afforded  immunity  for  the  mother — if  the  possibility  of 
independent  infection  of  the  embryo  by  the  father  is  accepted. 


Fig.  103. — Chancre  of  upper  lip.     (After  Duraesnil.) 


Great  care  is  necessary,  when  one  member  of  a  family  is  syphilitic,  to 
prevent  transmission  of  the  disease  to  others.  In  the  familiar  intercourse 
existing  between  immediate  relatives  great  danger  of  infection  exists.  This 
is  well  shown  by  several  cases  in  the  authors  experience.  In  two  instances 
a  careless  mother  infected  her  little  girl,  who  sulisequently  developed  marked 
secondary  syphilis.  In  another,  several  members  of  a  family  were  infected 
through  careless  handling  of  a  syphilitic  infant. 

There  are  many  interesting  examples  of  the  mediate  method  of  con- 
tracting s^'philis.    Instances  have  been  known  in  which  a  man  with  a  long 


^  L.  D.  Bulkley:     "Syphilis  in  the  Innocent.' 


METHODS    OF   ACQUIEING    SYPHILIS.  36? 

prepuce  has  had  intercourse  with  a  syphilitic  female  and  shortly  afterward 
with  his  wife,  infecting  the  latter,  while  he  himself  escaped  the  disease,  the 
virus  having  been  retained  beneath  the  prepuce  and  subsequently  deposited . 
in  the  healthy  vagina.  Again,  the  syphilitic  poison  may  be  deposited  in  the 
vagina  of  a  female  by  her  lover;  her  husband,  embracing  her  shortly 
afterward,  receives  the  souvenir  the  lover  left  him,  while  the  woman  herself 
escajDes.  These  facts  must  be  born  in  mind,  for  a  knowledge  of  them  may 
be  of  great  service  in  diagnosis.  Tobacco-pipes,  drinking-utensils,  and  the 
tubes  used  by  glass-blowers  are  familiar  media  of  syphilitic  contagion. 
An  instance  is  related  in  which  a  whole  glass-blowing  establishment 
became  infected  by  the  blow-pipe,  as  it  was  passed  from  mouth  to  mouth. 
One  of  the  workmen  had  a  few  small,  mucous  patches  in  his  mouth,  and 
from  this  man  the  whole  party  contracted  syphilis.  Vaccination  is  also 
a  familiar  mode  of  contagion,  less  frequently,  however,  than  is  generally 
supposed,  for  if  the  taint  of  generations  past  should  happen  to  manifest 
itself  at  the  time  of  vaccination,  particularly  if  humanized  virus  is  used, 
the  trouble  is  invariably  laid  at  the  door  of  the  doctor.  An  interesting 
instance  of  the  wide  dissemination  of  syphilis  by  mediate  transmis- 
sion is  one  in  which  an  entire  community  was  infected  by  an  itinerant 
tattoo  artist,  who  used  his  own  saliva  in  mixing  his  inks.  The  usual  ex- 
planation of  mucous  patches  in  the  mouth  holds  true  in  this  case.  Kline 
has  reported  an  instance  in  which  thirty  married  women,  nine  husbands, 
and  two  infants  either  mediately  or  immediately  contracted  syphilis  from 
a  syphilitic  midwife.^  A  possible  danger  of  contracting  syphilis  is  said  to 
be  the  custom  prevalent  among  some  cigar-makers,  of  biting  the  ends  of 
cigars  into  shape  and  sticking  the  wrappers  with  saliva.  Morrow  reported 
a  case  of  chancre  of  the  chin  from  a  scratch  with  a  barber's  razor.  Taylor 
also  mentions  having  seen  such  a  case.  Another  interesting  case  has  been 
reported  in  which  a  syphilitic  patient  cut  off  the  end  of  a  cigar,  that  he  had 
previously  held  in  his  mouth,  in  a  clip  such  as  is  seen  in  all  cigar  establish- 
ments; infectious  material  was  left  upon  a  cigar  subsequently  cut  in  the 
same  machine  by  a  healthy  person,  who  in  due  time  developed  labial  chancre 
and  secondary  syphilis.^ 

Duration  of  Chancre. — The  duration  of  syphilitic  chancre  is  variable. 
It  may  last  for  a  couple  of  weeks,  but  in  the  majority  of  cases  an  eruption 
appears  prior  to  the  disappearance  of  the  chancre. 

Numher  of  Chancres. — Chancre  is  generally  single,  but  may  be  multi- 
ple, according  to  the  number  of  points  primarily  inoculated.  It  is  usually 
situated  upon  the  genitals,  especially  often  behind  the  corona  glandis  in  the 
male,  but  its  situation  may  vary  greatly,  as  may  be  readily  understood  upon 


^British  Medical  Journal,  January  20,  188.3.   • 

-  To  those  especially  interested  in  syphilis  acquired  in  non-venereal  ways — syph- 
ilis insontium — Dr.  Bulkley's  work,  already  mentioned,  will  be  of  great  value. 


368 


SYPHILIS. 


considering  its  numerous  methods  of  contagion.     Chancres  of  the  face, 
tongue,  nipple,  and  fingers  are  not  so  very  rare,  and  instances  of  chancre 
.  of  the  tonsil  have  been  reported.     Urethral  chancre  is  not  uncommonly 
seen. 

Vaeieties  of  Chaxcke  as  a  Clinical  Extitt. — The  various  forms 
of  induration  of  chancre  have  already  been  described,  but  a  further  descrip- 
tion of  the  initial  sore,  particularly  of  the  ulceration,  may  be  of  service. 
Open  chancre  may  present:  1.  A  superficial  loss  of  epithelium  without  sup- 
puration, for  a  time  at  least;  this  is  termed  simple  erosion.  2.  A  greater 
or  less  area  of  ulceration — saucer-shaped — incidental  to  irritation  and  sec- 
ondary pus-infection.  3.  A  deep  ulcerative  excavation  with  sloping  edges. 
4.  Herpetiform  and  crustaceous  chancre  are  exceptionally  met  with.  5. 
"When  not  open — i.e.,  when  there  is  no  loss  of  tissue — the  chancre  occurs  in 


Fig.  104. — Hard  chancre  in  the  fossa  glandis.     (After  Dumesnil.) 


the  form  of  an  indurated,  non-secreting  jDapule  or  tubercle.    6.  Diphtheritic 
(diphtheroid)  chancre. 

Erosion  may  be  said  to  include  about  two-thirds  of  chancres,  and  is 
usually  situated  upon  the  mucous  membrane,  very  often  inside  the  prepuce 
in  the  male.  In  shape  it  is  oval,  or  perhaps  a  trifle  irregular,  with  a  raw, 
polished  surface  of  a  wine-red  color  and  sometimes  a  pultaceous  base,  but 
usually  secreting  a  simple  thin,  sanious  fluid,  devoid  of  pus,  or  at  least  con- 
taining a  very  small  amount  of  pus-corpuscles.  These  erosions  are  flat  and 
may  surmount  a  thin  parchment  induration,  or  ma}^  cap  a  hard  tubercle  as 
large  as  a  marble.  Superficial  ulceration  with  sloping  edges^the  ulcer 
presenting  a  saucer-shajDe — is  found  with  the  parchment,  but  most  often 
with  the  split-pea,  induration.  When  this  ulceration  ea^^s  a  large  mass  of 
induration,  it  is  likely  to  be  quite  deep  and  funnel-shaped  from  extensive 
necrobiosis,  constituting  the  so-called  "Hunterian  chancre."  The  secretion 
from  a  chancrous  ulceration  is  quite  likely  to  be  of  a  sero-purulent  char- 


COMPLICATIONS    OF    CHANCEE.  '669 

acter.  Herpetiform  and  crustaceous  chancre  may  occur  in  any  situation. 
The  simple  indurated  papule  or  tubercle  is  usually  found  upon  the  skin, 
the  integument  of  the  penis,  or  even  upon  the  prepuce  itself  Avhen  it  is 
short  and  dry.  Ulceration  of  this  form  of  induration  might  occur  if  it 
were  kept  moist,  the  conditions  of  warmth,  moisture,  and  irritation  com- 
bined being  especially  favorable  to  the  production  of  ulceration.  The  parts 
upon  which  it  develops  are  perhaps  not  so  rich  in  lymphatic  spaces  as 
those  in  which  a  chancre  is  more  likely  to  ulcerate,  the  collection  of  cells 
being  consequently  smaller  and  the  tendency  to  necrobiosis  less  marked. 
Several  unusual  types  of  chancre  have  been  described.  French  authors  de- 
scribe a  variety  called  the  ''herpetiform."  This  would  seem  from  its  de- 
scription to  be  simply  a  lesion  of  herpes  that  becomes  infected  with  syphilis 
and  eventually  indurates.  In  some  cases  the  rationale  of  its  formation  is 
exceedingly  simple.  At  the  time  of  exposure  to  syphilis  the  subsequently- 
infected  surfa'ce  comes  in  contact  with  some  local  irritant.  The  patient 
being  predisposed  to  herpes,  one  or  more  vesicles  develop  within  a  short 
time  after  exposure.  The  chancrous  induration  develops  in  the  herpetic 
lesion  later  on — at  the  end  of  the  period  of  incubation.  Fournier  describes 
a  form  of  chancre  that  he  terms  "crustaceous  chancre."  This,  he  claims, 
may  be  confounded  with  scabies,  which  latter  disease  may  present  pseudo- 
induration  and  inguinal  adenopathy.  This  condition  yields  to  sulphur, 
which  chancre  does  not.  Fournier  claims,  however,  that  expectancy  is  the 
only  recourse  in  the  differential  diagnosis  of  crustaceous  chancre. 

The  symptoms  of  urethral  chancre,  when  too  deep  to  be  seen  without 
the  urethroscope,  consist  in  a  discharge  coming  on  after  the  usual  period 
of  incubation,  this  discharge  being  thin,  and  perhaps  sanious,  but  some- 
times creamy  and  thick.  There  is  a  painful  spot  in  the  urethra  that  is  espe- 
cially noticeable  during  micturition  and  erection,  with  possibly  a  lump  in 
the  course  of  the  canal,  plainly  perceptible  on  palpation  with  the  thumb 
and  finger  in  some  cases.  The  character  of  the  discharge  depends  upon  the 
degree  and  character  of  the  complicating  urethritis.  The  characteristic 
symptoms  of  stricture  may  be  present,  produced  by  the  pressure  of  the 
chancre  upon  the  urethral  lumen.  By  means  of  the  urethroscope  an  ulcer 
may  often  be  detected,  and  in  a  short  time  the  general  enlargement  of  the 
glands  and  other  symptoms  clear  up  the  diagnosis.  Great  caution  is  neces- 
sary in  making  a  diagnosis  until  these  confirmatory  symptoms  appear.  The 
author  desires  to  call  attention  to  a  peculiar  form  of  urethral  chancre  that 
may  lead  to  grave  errors  in  diagnosis.  This  appears  as  a  slight  erosion  of 
a  milky  color,  just  within  the  meatus.  Induration  is  not  perceptible  and 
the  lesion  looks  not  unlike  an  intra-urethral  herpetic  lesion. 

Complications  op  Chancee. — There  are  some  complications  of  syph- 
ilitic chancre  that  demand  attention:  1.  First  and  simplest  we  have  vege- 
tations or  papillomatous  growths:  the  so-called  venereal  warts.  These  re- 
sult from  local  irritation  in  combination  with  heat  and  moisture,  and  are 


370  SYPHILIS. 

identic  with  vegetations  occurring  nnder  otlier  circumstances.  Tliey  liave 
already  been  discussed  in  a  preceding  cliapter  under  tlie  liead  of  non-vene- 
real lesions  of  the  penis.  The  author  will  reiterate  his  belief  that,  while 
simple  genital  papillomata  are  in  no  sense  syphilitic,  they,  like  herpes  pro- 
genitalis,  thrive  best  on  syphilitic  soil.  Proper  measures  of  cleanliness  will 
usually  prevent  the  formation  of  vegetations.  When  they  do  appear,  as 
they  will  in  some  persons  despite  all  care,  caustics  or,  better,  the  scissors 
are  necessary  for  their  removal.  2.  Inflammation  of  chancre — pus-infec- 
tion— sometimes  occurs,  giving  rise  to  considerable  pain  and  profuse  puru- 
lent secretion.  3.  Chancre  may  be  complicated  by  chancroid — constituting 
"mixed  sore,"  unless  the  two  forms  of  disease  appear  in  different  locations. 
4.  Chancre  may  be  attacked  by  phagedena  or  gangrene. 

Mixed  Chancre. — When  a  chancre  becomes  inoculated  Avith  chan- 
croid, its  ulceration  deepens  and  it  gradually  assumes  the  general  characters 
of  chancroid,  but  unless  phagedena  occurs  induration  usually  still  persists. 
Oftener  than  is  usually  supposed,  however,  the  chancroidic  process  inhibits 
the  development  of  chancrous  induration,  or  initial  sclerosis — as  a  conse- 
quence, syphilis  oftentimes  follows  an  apparently-typic  soft  sore.  Slight 
sclerosis  is  very  apt  to  be  melted  away,  so  to  speak,  by  the  chancroidic  in- 
fection, and  thus  escape  attention.  When  chancroid  develojjs  primarily 
— from  typic  mixed  infection — it  generally  runs  its  usual  course,  until  the 
incubation  period  of  syphilis  has  elapsed,  when  induration  occurs.  The 
secretion  of  the  mixed  sore  is  autoinoculable,  and  capable  of  transmitting 
either  disease  alone,  or  both  together,  to  a  healthy  person.  In  some  cases 
chancroid  appears  and  rapidly  heals,  or  the  incubation-period  of  syphilis 
is  long,  and  induration  develops  in  the  cicatrix  of  the  chancroid  after  it  has 
soundly  healed. 

The  test  for  mixed  chancre  is  autoinoculation.  Any  indurated  sore, 
the  secretion  of  which  is  autoinoculable  in  the  true  sense  of  the  word,  and 
which  is  followed  by  constitutional  syphilis,  is  a  mixed  chancre.  By  the 
term  autoinoculable  is  meant  a  sore  the  secretion  of  which,  inoculated  in 
a  new  situation  in  the  diseased  individual,  will  produce  typic  chancroid. 

The  methods  of  contraction  of  mixed  chancre  are  tAVO,  viz.:  (1)  both 
poisons  may  be  contracted  simultaneously,  or  (2)  either  variety  of  genital 
lesion  may  develop  primarih',  and  subsequently  become  inoculated  Avith  the 
other  form  of  disease. 

Typic  syphilitic  chancre  —  initial  sclerosis  —  may  undergo  marked 
transformations:  e.g.,  a  chancrous  induration,  particularly  when  situated 
in  a  moist  locality  such  as  a  mucous  or  cjuasimucous  surface,  may  lose  its 
hardness  and  at  the  same  time  become  transformed  into  a  quasimucous 
patch  by  becoming  covered  Avith  a  characteristic  whitish  pellicle.  In  some 
instances  the  sore  acquires  the  form  of  the  mucous  patch  yet  retains  its 
characteristic  induration.  MorroAv  has  described  a  "diphtheritic"  A^ariety 
of  chancre.     It  is  possible  that  this  may  sometimes  be  the  mucous  trans- 


TEEATMEXT    OF    CHANCRE.  371 

formation  just  described,  and  not  a  special  variet}^  of  lesion,  but  the  author 
has  met  with  cases  corresponding  exactly  with  Morrow's  description. 

Phagedenic  Chancke. — Phagedena  may  attack  true  chancre,  and  when 
it  does  so  is  quite  likely  to  be  of  the  gangrenous  form.  The  pultaceous  and 
serpiginous  varieties  are  cjuite  rarely  seen  under  such  circumstances.  After 
phagedena  has  once  invaded  a  chancre  induration  is  no  longer  perceptible. 
If  the  sore  be  of  the  mixed  variety,  the  pultaceous  or  serpiginous  form  of 
phagedena  is  then  quite  likely  to  develop.  Such  authorities  as  Bassereau 
and  Diday  think  that  the  type  of  syphilis  following  phagedenic  chancre  is 
apt  to  be  exceptionally  severe.  This  is  true  in  the  authors  experience,  but 
is  explicable  by  the  fact  that  phagedena,  per  se,  is  probably  due  either  to 
general  debility  or  a  peculiar  diathesis  that  lessens  both  local  and  systemic 
resistance  to  disease  and  especially  to  syphilis,  rather  than  by  an  extraor- 
dinary intensity  of  the  syphilitic  infection.  The  question  of  a  special  germ- 
infection  in  phagedena  is  still  suh  judice. 

Treatment  of  Chancre. — The  treatment  of  syphilitic  chancre  is  very 
simple  when  no  comj)lications  exist.  The  yellow  or  black  wash  may  be  ap- 
plied, and  are  the  best  aj^plications  that  can  be  used.  According  to  the 
new  pharmacopeia,  the  lotio  flava,  or  yellow  wash,  consists  of  18  grains  of 
the  bichlorid  of  mercury  to  10  ounces  of  liquor  calcis,  and  the  lotio  nigra, 
or  black  wash,  of  30  grains  of  calomel  to  10  ounces  of  liquor  calcis.  These 
preparations  should  be  well  shaken  before  being  used,  else  very  little  of  the 
salt  of  mercury,  Avhich  exists  in  the  form  of  a  precipitate,  will  be  applied. 
The  mild  chlorid  of  mercury  with  zinc  oxid  forms  a  very  efficient  dressing. 
Europhen,  nosophen,  and,  if  the  lesion  is  painful,  orthoform,  are  useful 
applications. 

Cauterization  of  simple  hard  chancre  should  never  be  practiced,  as  it 
will  simply  cause  painful  inflammation  and  perhaps  sloughing  in  an  other- 
wise locally  insignificant  lesion.  If,  however,  the  sore  is  of  the  mixed 
variety,  its  chancroidic  property  should  be  destroyed  by  cauterization,  after 
which  iodoform  in  powder  should  be  applied.  All  sources  of  irritation 
should  be  carefully  avoided  and  perfect  cleanliness  insisted  upon.  The 
author  believes  that  the  internal  administration  of  mercury  should  be  begun 
as  soon  as  the  diagnosis  of  syphilitic  chancre  is  perfectly  clear.  By  follow- 
ing this  course  there  are  seldom  any  manifestations  of  the  disease  other 
than  a  slight  roseola,  with  perhaps  a  few  trifling  mucous  patches,  during 
the  entire  course  of  treatment.  It  is  very  important  to  prevent  eruptions, 
especially  upon  the  face.  Whenever,  on  the  other  hand,  there  is  the  slight- 
est doubt  as  to  the  correctness  of  the  diagnosis,  no  mercury  should  be  given 
until  the  question  is  decided  by  the  appearance  of  symptoms  unequivocally 
syphilitic. 

In  a  general  way  it  is  to  be  remembered  that  uncomplicated  chancre 
is  of  little  importance  locally.  It  usually  causes  very  little  annoyance  if  not 
tortured  by  overtreatment.    With  the  use  of  black  or  yellow  wash,  calomel, 


372  SYPHILIS. 

nosojDlien,  enrojjlien,  or  iodoform  powder,  or  even  absorbent  cotton  as  a 
dressing,  the  induration  ma}'  nsuallj''  be  left  to  take  care  of  itself.  Should 
the  snrgeon  wish  to  see  by  contrast  the  results  of  meddlesome  ofhciousness, 
let  him  rub  a  hard  chancre  with  pure  nitrate  of  silver,  and  then  apply  some 
nasty,  greasy  ointment.  The  result  will  be  a  condition  of  affairs  often  seen 
in  patients  who  have  been  treated  in  this  manner  by  physicians,  drug-clerks, 
or  ver}^  often  by  themselves.  Greasy  applications  and  nitrate  of  silver 
should  be  avoided  as  abominations,  else  the  patient's  confidence  will  quite 
likely  be  lost.  It,  as  in  the  case  of  mixed  sore,  it  becomes  necessary  to  cau- 
terize, the  surgeon  should  use  a  caustic,  and  have  done  with  it,  and  not 
apply  an  irritant  like  nitrate  of  silver,  which  sears,  but  does  not  destroy. 
Carbolic  acid  followed  by  the  fuming  nitric,  pure  bromin  or  the  actual 
cautery  should  be  used.  The  form  of  caustic  is  not  so  important  as  the 
manner  of  its  use.  The  surgeon  should  select  a  caustic  early  in  practice, 
and  stand  by  it  until  he  learns  how  to  use  it.  The  patient  should  be 
instructed  in  the  matter  of  rest.  Much  may  be  accomplished  by  avoiding 
sexuality  in  thought  and  action,  by  taking  very  little  exercise,  abstaining 
from  stimulants,  and  lastly  b}^  handling  the  affected  part  as  little  as  pos- 
sible. The  oftener  the  patient  examines  himself  to  note  the  progress  of  the 
ease,  the  worse  his  chancre  will  eventually  be.  Occasionally  a  chancre  will 
become  phagedenic,  in  which  event  special  measures  of  treatment  become 
necessary,  as  seen  in  connection  with  phagedenic  chancroid.  Free  stimula- 
tion and  local  cauterization  with  the  actual  cautery  or  pure  bromin,  followed 
by  strict  antisepsis,  are  the  jDrincipal  indications.  Tonics  and  opium  must 
be  given.  Opium  was  especially  indorsed  by  Eicord.  In  the  author's  ex- 
perience it  has  seemed  to  be  of  service.  It  is  certainly  useful  in  relieving 
pain  and  nervous  irritation  in  such  cases.  Mercury  is  necessary  to  combat 
the  debilitating  eff'ects  of  the  constitutional  syphilis  in  phagedena.  It 
should  be  given  very  guardedly,  howe^^'er,  and  in  tonic  rather  than  specific 
doses  in  most  cases. 

Excision  of  Chancre. — There  is  one  radical  method  of  dealing  with 
chancre  that  deserves  special  attention,  viz.:  treatment  by  excision.  It  is 
claimed  by  some  advocates  of  this  method  that  by  it  the  general  symptoms 
are  modified  and  in  some  instances  prevented  entirely,  not  even  the  indolent 
glandular  changes  being  perceptible.  Theoretically,  if  the  views  of  the 
pathology  of  the  disease  that  have  been  presented  in  the  ^^receding  chapter 
b.e  correct,  excision  of  the  initial  sclerosis  ought  to  prevent  general  infection 
completely,  but  unfortunately  this  has  as  yet  to  be  proved  to  be  the  case  in 
actual  practice.  The  author  has  given  the  method  some  attention  and  has 
performed  excision  in  selected  cases  whenever  the  patient's  consent  could  be 
obtained.  The  cases  thus  treated  number  about  sixt}^,  some  of  which  could 
be  carefully  followed  thereafter,  while  others  passed  from  under  observation. 
In  his  earlier  cases  the  author  was  inclined  to  believe  that  the  operation 
was  of  benefit  constitutionally.     Subsequent  experience,  however,  has  seem- 


EXCISIOX    OF    CHAXCEE.       PEIMAKY    ADENOPATHY.  373 

ingly  shown  that  excision  is  of  value  only  in  meeting  certain  local  indica- 
tions of  a  special  character. 

Excision  of  chancre  should  be  performed  only  after  the  induration  has 
matured:  i.e.;  after  it  has  attained  full  development  and  has  remained  in 
statu  quo  for  some  days.  Otherwise  induration  is  likely  to  recur  in  the 
edges  of  the  wound. ^  There  are  several  arguments  that  have  been  advanced 
in  favor  of  excision  which  are  in  the  main  acceptable,  viz.:  1.  We  thereby 
remove  a  constant  focus  of  infection  that  is  present  so  long  as  the  induration 
persists.  2.  We  at  once  remove  a  large  mass  of  syphilized  cells  that  would 
otherwise  only  be  removed  by  the  slower  process  of  fatty  degeneration,  ab- 
sorption, and  elimination.  3.  We  obviate  the  possibility  of  the  transmis- 
sion of  the  disease  to  others  by  means  of  the  initial  lesion — a  point  of  great 
importance  to  married  persons.  4.  We  lessen  the  danger  of  suppurating 
bubo,  in  case  the  chancre  should  become  inflamed  or  pus-infected.  5.  We 
remove  a  constant  source  of  irritation  and  lessen  the  danger  of  phagedena 
and  inflammation  that  might  disable  the  patient.  6.  The  patient  is  able 
to  resume  his  marital  relations  immediately  the  incision  has  cicatrized  per- 
fectly.^ Why  we  cannot  prevent  constitutional  syphilis  by  excision  of  chan- 
cre prior  to  local  glandular  changes  is  not  clearly  explicable,  if  we  accept 
the  view  that  the  disease  is  practically  local  primarily.  It  is  probable  that 
the  syphilitic  infection,  which  begins  at  the  moment  of  inoculation,  has 
extended  far  beyond  the  limits  of  the  initial  lesion  before  the  appearance 
of  the  latter.  Then,  too,  improbable  as  it  may  appear,  syphilis  may  possibly 
be  a  complex  infection  with  both  local  and  constitutional  elements. 

Operation. — Excision  of  the  chancre  should  be  preceded  by  washing  the 
parts  in  a  solution  of  bichlorid  of  mercury  1  to  1000.  If  ulceration  exists  it 
should  then  be  cauterized  and  dusted  w4th  calomel.  The  chancre  should 
now  be  transfixed  with  a  tenacrdum,  raised  from  its  bed,  and  the  mass  of 
induration  quickly  removed  with  a  sharp  scalpel  or  curved  scissors.  The 
incision  sliould  be  sutured  with  fine  catgut,  dry  dressings  applied,  and  the 
patient  kept  at  rest  for  a  few  days.  Within  forty-eight  hours,  as  a  rule,  the 
wound  will  have  united.  In  a  week  or  two,  if  there  is  no  penile  lesion,  the 
patient  may  resume  his  marital  relations,  providing  some  measure  of  pro- 
tection of  the  wife  be  adopted,  such  as  the  use  of  protectives  or  antiseptic 
unguents- and  irrigations. 

Primaey  Adenopathy.  —  The  glandular  enlargements  that  succeed 
the  appearance  of  the  initial  sclerosis  or  chancre  have  already  been  noted. 
These  are  ordinarily  termed  "syphilitic  bubo."  The  term  primar}^  adenop- 
athy is  more  comprehensive  and  much  more  accurate  pathologically.  Pri- 
mary adenopathy  may  occur  in  any  situation  where  there  are  lymphatic 
glands  in  the  vicinity  of  a  chancre,  being  therefore  most  often  found  in  the 


^  Xote  case  on  page  .358. 

^Otis:     "Class-room  Lessons  in   Syphilis." 


374  SYPHILIS. 

groin.  The  groups  of  glands  involved  vary  according  to  the  location  of  the 
chancre.  In  chancre  of  the  penis,  urethra,  groin,  buttocks,  anus,  lower  part 
of  the  abdomen,  scrotum,  thighs,  or  rectum,  the  inguinal  or  femoral  glands 
or  both  are  involved.  In  chancre  of  the  lips  and  mouth  the  submaxillary 
lymphatics,  and  in  chancre  of  the  face,  the  pre-aural  glands  are  involved. 
When  the  finger  is  inoculated,  we  have  enlargement  of  the  glands  in  the 
axilla.  The  epitrochlear  gland  is  not  usually  enlarged  until  secondary 
adenojDath)^  develops,  for  it  connects  only  with  the  deeper  lymphatic  ves- 
sels. General  glandular  enlargement  eventually  occurs,  but  the  changes  are 
first  evident  in  the  contiguous  glands,  and  they  are  always  more  markedly 
enlarged  than  any  of  the  others. 

When  the  inguinal  glands  are  implicated,  they  are  grouped  in  a  peculiar 
fashion.  This  group,  termed,  by  Eicord,  the  "jDleiad,"  consists  usually  of 
one  large  gland  surrounded  by  from  two  or  three  to  six  or  eight  of  smaller 
size.  The  enlargement  is  generally  not  very  extensive,  but  is  peculiar  in 
some  respects.  There  is  little  or  no  pain  or  tenderness,  and  the  glands  are 
freely  movable  under  the  skin,  being  distinctly  outlined  and  not  matted 
together.  As  a  rule,  they  have  tbe  hard  woody  feel  observed  in  the  chancre, 
but  exceptionally  they  are  softer  and  more  elastic.  Enlargement  of  the 
glands  begins  usually  about  the  beginning  of  the  second  week  after  the  ap- 
pearance of  the  chancre,  and  Fournier  stjdes  a  case  in  which  enlargement 
did  not  occur  until  the  twenty-seventh  day  as  unique.  Instead  of  the 
peculiar  group  known  as  the  pleiad,  there  may  be  only  one  moderately 
enlarged  gland,  or  perhaps  a  single  swelling,  as  large  as  a  hen's  egg,  on  one 
or  both  sides.  Dissection  shoAvs  that,  as  originally  claimed  by  Bassereau, 
such  swellings  consist  of  small  glands  matted  together  with  enlarged  lym- 
phatic vessels  and  firm  connective  tissue. 

Syphilis  d'Emtlee. — The  form  of  bubo  without  a  pre-existing  chancre, 
hubon  d'emblee, — already  expatiated  upon  in  the  chapter  on  bubo, — was  for- 
merly much  talked  of  in  France.  The  syphilis  following  this  variety  of 
bubo  has  been  termed  syphilis  d'emhke.  Taylor  very  properly  styles  syphilis 
d'emhlee  "a  myth,"  but  there  are,  nevertheless,  occasional  cases  that  are  very 
puzzling  at  first  sight.  The  author  has  seen  a  number  of  cases  in  which  the 
first  perceptible  manifestation  of  trouble  was  in  the  inguinal  glands,  typic 
syphilis  following  in  due  course  in  each  case.  These  patients  were  under 
constant  observation  and  had  inspected  themselves  regularly  and  carefully, 
yet  absolutely  no  evidences  of  a  local  focus  of  infectioiL  were  discovered. 
The  author  does  not  believe  that  general  syphilis  can  occur  without  pre- 
existing initial  sclerosis  of  greater  or  less  degree  of  development,  but  in 
such  cases  as  those  described  it  must  necessarily  be  very  insignificant  as  well 
as  ephemeral. 

The  important  practical  stand-point  to  remember  in  connection  witb 
syphilitic  bubo  is  that  each  individual  gland  is  but  a  repetition  of  the 
neoplastic  formation  of  which  the  chancre  is  the  prototype.     Its  hard  and 


PEIMAEY   ADENOPATHY.  375 

woody  feel,  comparative  j^ainlessness,  perfect  circumscription  and  indis- 
position to  suppuration,  depend  upon  the  same  characteristic  histologic 
features  that  have  been  studied  in  the  initial  lesion.  Under  the  microscope 
there  appears  the  same  collection  of  cells  of  varying  forms — the  large  round 
multinucleated  granular  cell  being  in  preponderance — and  the  same  pro- 
liferation of  the  surrounding  connective  tissue  seen  in  a  section  of  hard 
chancre. 

Primary  adenopathy  attains  its  full  development  in  from  one  to  three 
weeks,  and  may  then  remain  stationary  for  some  weeks  or  months.  It  may 
even  last  for  over  a  year.  It  is  usually  present,  and  may  suddenly  increase 
in  size  when  the  earh^  eruptions  appear.  In  exceptional  instances  it  may 
speedily  disappear  from  unknown  causes.  Suppuration  rarely  attacks  syph- 
ilitic adenopathies,  and  when  it  does  occur  is  the  result  of  secondary  mixed 
infection,  favored  by  mechanic  irritation  or  a  strumous  diathesis,  and  its 
pus  is  not  autoinocuiable.  When  pus  from  suppurative  adenitis  is  auto- 
inoculable,  the  primary  sore  must  necessarily  have  been  either  a  mixed  sore 
or  pure  chancroid.  Induration  of  contiguous  lymphatic  vessels  and  glands 
is  so  rarely  absent  in  syphilitic  chancre  that  practically  it  may  be  said  to 
always  exist.  It  is  likely  to  be  absent  in  cases  of  second  infection,  and, 
according  to  Eieord,  is  not  present  in  phagedenic  chancre.  The  author  has 
seen  several  cases  of  phagedenic  sloughing  in  hard  chancre,  in  which  pri- 
mary adenopathy  did  not  appear,  although  general  and  inguinal  adenop- 
athy developed  in  connection  with  the  general  symptoms.  The  author  has 
no  explanation  to  offer  for  this,  and  it  must  be  confessed  that  it  does  not 
enhance  the  strength  of  the  position  assumed  as  to  the  pathology  of  the 
disease.  Such  cases  naturally  bring  up  a  question  to  which  allusion  has 
already  been  made,  viz.:  whether  there  ma}^  not  be  two  elements  in  the 
syphilitic  infection,  one  local  and  the  other  constitutional — one  acting  via 
the  lymphatics  alone  and  the  other  through  the  general  circulation. 

In  cases  in  which  there  is  considerable  subcutaneous  fat  adenopathy 
may  not  be  perceptible.  As  a  rule,  the  enlarged  glands  gradually  attain 
their  maximum  development,  and  as  gradually  disappear,  either  spontane- 
ously or  under  the  action  of  mercury,  in  the  same  manner  as  the  chancre 
itself  eventually  resolves.  Although  they  never  suppurate  when  uncom- 
plicated, these  glandular  enlargements  are  prone  to  caseous  degeneration 
when  the  subject  is  of  a  strumous  or  tubercular  diathesis.  Bubo  may  recur 
during  the  active  period  of  sj^philis  and  long  after  glandular  trouble  has 
apparently  ceased.  Eecurrent  adenopathy  has  already  been  expatiated 
upon. 

The  treatment  of  syphilitic  bubo  is  that  of  general  syphilis,  unless  sup- 
puration occurs,  in  which  event  it  must  be  treated  upon  ordinary  surgical 
principles.  This  subject  has  been  fully  expatiated  upon  under  the  special 
heading  of  "A^enereal  Adenitis,  or  Bubo." 


CHAPTER  XYI. 

Geneeal  I>«rrECTio:bT  of  Syphilis. 

The  most  important  subject  in  the  consideration  of  syphilis  is  the 
period  during  which  constitutional  manifestations  appear^,  the  period  of 
systemic  infection,,  or,  as  Otis  terms  it,  "localized  cell-accumulation."  The 
period  covering  the  development  of  the  chancre  with  its  attendant  and  con- 
secutive Ijanphitis  and  adenitis,  which  we  have  termed  the  initiatory  period, 
oi:,  if  we  may  use  the  expression,  local  syphilis,  is  more  frequently  known 
as  primary  syphilis.  Congenital  syphilis — so-called  inherited  syphilis — has 
no  initiatory  period,  being  general  from  its  very  commencement,  but  ac- 
quired syphilis  has  always  a  primary  stage.  This  is  of  great  practical  im- 
portance, for  wherever  we  meet  secondary  syphilis  we  can  positively  affirm 
that  there  must  necessarily  have  been  an  initial  sclerosis,  of  greater  or  less 
degree,  somewhere,  and  this  must  have  been  attended  by  primary  adenop- 
athy— adenitis — however  obscure  or  slight  the  latter  may  have  been.  It 
is  sometimes  very  important  to  decide  where  these  local  changes  were  mani- 
fest.   The  following  is  an  illustrative  case: — 

Case. — The  author  was  consulted  by  a  young  woman  who  was  suffering  from 
active  secondary  syphilis  the  origin  of  which  she  professed  to  be  entirely  ignorant  of. 
Her  relatives  seemingly  had  no  suspicion  as  to  the  possible  source  of  her  trouble,  and 
she  was  brought  for  consultation  by  the  gentleman  to  whom  she  was  engaged  to 
be  married.  This  gentleman  had  his  own  suspicions,  but  generously  gave  the  woman 
the  benefit  of  the  doubt  existing  in  his  own  mind,  as  to  the  possibility  of  her  having 
contracted  some  simple  disease  by  kissing,  he  himself  having  a  sore  mouth  at  the 
time.  A  careful  investigation  revealed  the  fact  that  she  had  never  had  the  slightest 
trouble  with  her  mouth  or  throat  until  the  secondary  pharyngeal  manifestations 
appeared,  and,  in  addition,  she  innocently  stated  that  she  had  had,  about  a  year 
previous  to  her  consulting  me,  some  small  tender  "lumps"  in  the  groins.  There  had 
never  been  any  "kernels,"  as  she  termed  them,  in  the  neck  beneath  the  jaws.  The 
throat  and  mouth  lesions  were  typic  mucous  patches.  These  various  points  settled 
the  question  as  to  the  locality  primarily  affected,  and  a  candid  statement  of  the  case 
saved  the  young,  man  from  a  mesalliance.  The  woman  is  probably  congratulating 
herself  upon  her  success  in  duping  her  physician,  but  wondering  at  the  disappearance 
of  her  affianced,  he  having  withdrawn  in  the  easiest  manner  possible  by  leaving  the 
city. 

The  initiatory  period  of  syphilis  terminates  when  the  infection  has 
traversed  the  lymphatics  leading  from  the  chanerous  surface,  entered  the 
receptaculum  ch3di,  and  from  thence  passed  into  the  blood,  through  the 
medium  of  which  it  is  disseminated  throughout  the  system,  giving  rise  to 
the  peculiar  changes  characteristic  of  syphilis,  in  every  tissue  and  organ, 
the  changes  being  more  marked  in  some  organs  perhaps  than  in  others  in 
different  cases,  but  there  being  no  tissue  that  enjoys  complete  immunity 
from  the  ravages  of  the  disease.    As  will  be  seen  later,  the  various  bodily 

(376) 


PATHOLOGY  OF  GENERAL  SYPHILITIC  INFECTION.  377 

functions  may  be  impaired;  the  bones,  viscera,  and  blood-vessels  invaded; 
the  special  senses  and  sexual  appetite  destroyed,  paralyses  may  occur,  and 
even  the  intellect  itself  may  be  ruined  by  it. 

Pathology  of  Geneeal  Syphilitic  Infection. — As  already  seen, 
the  period  of  local  manifestations  of  syphilis  is  preceded  by  a  period  of  in- 
cubation, lasting,  on  an  average,  twenty-one  days.  Following  the  initiatory 
period,  with  its  initial  sclerosis  and  primary  adenopathy,  there  is  another 
apparent  period  of  incubation  lasting,  on  an  average,  forty  to  forty-five  days, 
and  followed  by  general  sj^mptoms.  It  would  appear  that  these  periods  of 
quiescence  are  not  true  periods  of  incubation,  but  are  periods  during  which 
there  is  an  interference  with  the  progress  of  the  infection  by  "normal  an- 
atomic and  physiologic  barriers."  During  the  so-called  second  stage  of 
incubation  (this  stage  will  shortly  be  subdivided  into  several  incubative 
periods),  which,  as  we  have  seen,  lasts,  on  an  average,  forty  to  forty-five 
days,  the  syphilitic  infection  is  slowly  traversing  the  lymphatics  and  grad- 
ually making  its  way  to  the  general  blood-current.^  It  is  not  fermenting, 
and  thus  preparing  for  an  explosion,  but  is  slowly  traveling  on  through  the 
lymphatic  system,  the  cells  that  act  as  carriers  proliferating  and  multiply- 
ing by  the  way,  and  not  only  changing  themselves,  but  by  virtue  of  the 
infection  they  bring  exciting  propensities  for  evil  in  the  lymphatic  and  con- 
nective-tissue elements  with  which  they  come  in  contact,  imparting  to  them 
their  own  infectious  and  other  morbid  properties,  particularly  their  morbid 
activity  and  abnormal  tendency  to  proliferation. 

Periods  of  JRetardation  or  Apparent  Quiescence. — Generally — practically 
always  in  typic  cases — only  the  chain  of  glands  intervening  between  the 
local  induration  and  the  lymphatic  reservoir  or  receptaculum  cliyli  are  in- 
durated until  immediately  before,  coincidentally  with,  or  soon  after  the 
manifestations  of  general  syphilis.  Often,  however,  the  general  lymphatic 
sj^stem  is  involved  some  time  prior  to  the  appearance  of  the  eruption,  in 
which  event  there  is  an  undoubted  increase  in  size  coincident  with  the  erup- 
tion. jSTow,  why  is  it  that  there  is  (a)  an  interval  between  the  appearance  of 
the  local  induration  and  the  enlargement  of  the  nearest  lymphatic  glands,  (b) 
another  between  this  glandular  enlargement  and  general  glandular  hyper- 
plasia, and  (c)  still  another  sometimes  betAveen  the  general  glandular  en- 
largement and  the  appearance  of  the  eruption?  Excellent  hypothetic  reasons 
can  be  given  for  these  circumstances:  In  the  first  place,  if  it  be  granted 
that  the  cells  alone  carry  the  infection,  as  Otis  claims,  a  certain  length  of 
time  must  elapse  before  they  can  leave  the  original  focus  of  infection, — i.e., 
the  chancre, — traverse  the  intervening  lymphatic  vessels,  and  arrive  in  the 
nearest  lymphatic  glands.     Here  the  infection  produces  its  characteristic 


^  Otis  insists  upon  this  point  with  especial  emphasis,  laying  stress  upon  the  slow 
and  systematic  progress  of  the  "germinal  cells,"  for  which  the  author  has  substituted 
the  term  infection. 


378  GENERAL    IXFECTION    OF    SYPHILIS. 

effects,  as  evidenced  b}^  the  deyelopment  of  primary  adenopatli}^,  and,  wliile 
the  glands  become  enlarged,  some  of  the  infected  cells  that  have  excited 
the  morbid  changes — with  others  that  have  joined  them  and  become  in- 
fected b}^  the  wa}' — travel  slowly  on  toward  the  receptaculum  chyli  and 
thence  to  the  general  system  by  way  of  the  general  circnlation.  This  re- 
qnires  a  certain  interval  of  time,  for  no  morbid  manifestations  can  occnr 
nntil  the  infection  has  reached  its  destination. 

Geneeal  Adenopathy. — As  we  have  seen,  the  syphilitic  infection 
eventually  arrives  at  the  receptaculum  chyli,  from  which  it  is  carried  to  the 
general  circnlation  and  after  entering  the  right  heart  is  finally  disseminated 
throughout  the  tissues  generally,  producing  its  characteristic  effect  of  cell- 
proliferation,  a  first  evidence  of  which  may  consist  in  a  general  glandular 
enlargement  sometimes  seen  prior  to  the  eruption. 

In  cases  in  which  general  adenopathy  occurs  prior  to  the  appearance 
of  an  eruption — the  possibility  of  this  is  denied  by  some,  good  authorities 
claiming  that  glandular  enlargement  is  always  coincident  with,  or  consecu- 
tive to,  the  eruption,  the  author's  experience  being  that  the  glands  often 
become  enlarged  prior  to  the  eruption — there  is  a  consequent  interval  be- 
tween general  adenopathy  and  the  syphilitic  eruption.  This  is  due  to  the 
fact  that,  although  the  infection  arrives  in  other  tissues  of  the  body  through 
the  medium  of  the  blood,  quite  as  soon  as  in  the  lymphatics,  the  latter  are 
likely  to  be  the  first  tissues  to  respond  to  the  infection  by  virtue  of  their 
relatively-greater  susceptibility.  The  glands  are  not  examined  as  often  as 
they  should  be  before  the  eruption  appears,  else  they  would  be  found  to  be 
more  frequently  enlarged  prior  to  the  eruption  than  is  generally  believed. 
If  the  lymphatic  glands  are  already  enlarged  when  the  eruption  appears, 
they  immediately  still  further  increase  in  size,  the  proliferation  of  cells 
being  excited  to  renewed  activity  at  this  time.  Theoretically,  then,  there 
would  seem  to  be  good  and  sufficient  reasons  for  the  three  apparent  periods 
of  incubation,  which,  if  correct,  demonstrate  that  they  are  not  true  periods 
of  incubation  or  quiescence,  but  are  periods  of  retardation  during  which  the 
infection  is  still  slowly  progressing  and  which  are  really  necessary,  in  order 
that  the  infection-bearing  cells  maj^  reach  the  tissues  that  are  successively 
involved. 

The  first  period  of  incubation  occurring  in  the  natural  course  of  syph- 
ilis has  not  yet  been  discussed  in  detail.  It  can  be  explained  along  the 
same  lines  as  the  other  periods  of  quiescence.  This  first  period  of  incuba- 
tion is  the  most  important  of  all  the  so-called  incubative  periods,  and  like 
the  others  is  apparent  and  not  real.  This  may  be  disputed  even  by  those 
who  are  willing  to  accept  the  other  stages  of  quiescence  as  only  apparent. 
The  period  intervening  between  the  inoculation  with  infectious  material 
and  the  appearance  of  the  initial  sclerosis  would  certainly  appear  to  be  a 
stage  of  true  incubation.  It  would  seem  from  the  long  stage  of  quiescence 
that  the  infection  of  syphilis  is  undergoing  a  sort  of  development  or  fer- 


GENEEAL    ADENOPATHY.      THE    EOSEOLA.  379 

mentative  change,  at  the  culmination  of  which  an  explosion  naturally 
follows  in  the  form  of  a  chancre.  It  is  the  author's  belief,  as  formed  from 
a  careful  survey  of  the  investigations  and  teachings  of  Besiadecki,  Baum- 
ler,  Otis,  and  others,  that  local  changes  begin  as  soon  as  the  syphilitic 
virus  has  been  absorbed.  These  changes  are  very  gradual,  it  is  true,  and 
probably  consist,  at  first,  of  the  incorporation  of  the  syphilitic  infection 
with  the  lymphatic  elements  of  the  infected  tissues.  Logically  enough  it 
may  be  inferred  to  be  the  incorporation  of  an  infectious  micro-organism 
with  the  normal  cell-elements. 

A  certain  length  of  time  is  necessary  before  the  infection  reaches  the 
lymph-spaces,  and,  again,  some  little  time  is  necessary  for  its  incorporation 
with  the  lymph-cells.  There  now  begins  a  slow  proliferation  of  the  lym- 
phatic elements  that  are  now  syphilitic  germinal  cells  possessed  of  new  and 
morbid  properties  as  well  as  an  intensification  of  their  physiologic  proper- 
ties. The  chief  new  and  morbid  property  that  they  have  acquired  is  in- 
fectiousness, and  the  normal  properties  already  existing,  but  which  now 
become  intensified,  are  those  of  ameboid  activity  and  power  of  prolifera- 
tion. The  multiplication  of  cells  becomes  more  active,  the  connective-tis- 
sue elements  of  the  blood-vessels  and  lymphatic  walls  become  involved, 
producing,  as  we  have  already  seen,  partial  occlusion  of  their  lumen  and 
consequent  "anemia  of  tissue."  The  smaller  lymphatic  vessels  are  now 
reached  and  the  accumulation  of  cells  is  so  extensive  that  perceptible  in- 
duration is  noticed.  This  area  of  induration  increases  in  size  until  the  cell- 
accumulation  of  which  it  is  composed  has  free  communication  with  the 
larger  lymphatics  and  the  smaller  lymphatics  regain  their  permeability. 
From  this  time  on  the  cells  are  removed  b}'  the  lymphatics  as  fast  as  formed. 
Finally,  local  proliferation  having  entirely  ceased,  the  cells  composing  the 
induration  are  entirely  removed  by  the  absorbents  or  undergo  fatty  de- 
generation and  resolution  from  the  administration  of  mercury  or  potassic 
iodid. 

It  will  be  observed  that,  including  the  primary  stage  of  apparent  quies- 
cence, four  apparent  stages  of  incubation  have  been  described,  while  ordi- 
narily but  two  are  described,  one  of  which  precedes  the  development  of  the 
chancre,  and  is  universally  termed  a  period  of  true  incubation,  and  the 
other,  deemed  by  some  a  true  and  by  others  an  apparent  period  of  incuba- 
tion, intervening  between  the  primary  and  secondary  syphilitic  manifesta- 
tions. The  author  believes,  however,  that  on  careful  consideration  the 
intervals  that  have  been  described  will  be  sufficiently  plain. 

The  Eoseola. — At  the  end  of  about  forty  to  forty-five  days,  on  the 
average,  after  the  development  of  the  initial  sclerosis  the  period  of  "general 
S3^stemic  infection  and  localized  cell-accumulation"  begins,  the  infection 
having  now  reached  its  final  destination.^     The- first  evidence  of  general 


^  Tide  Otis :    "Class-room  Lessons  in  Syphilis." 


380  GENERAL    INFECTION    OF    SYPHILIS. 

infection  consists  in  the  development  of  a  peculiar  eruption  of  rose-colored 
spots:  the  syphilitic  roseola.  Although  this  eruption  may  escape  observa- 
tion, it  is  probably  constant,  being  always  present  in  a  greater  or  less  de- 
gree, in  some  cases  lasting  for  a  number  of  weeks,  probably  from  two  to 
eight,  while  in  others  it  may  last  only  a  few  hours.  In  its  general  appear- 
ance the  eruption  is  not  very  unlike  measles.  The  spots  are  of  a  dull  rose- 
red  hue,  and  disappear  on  pressure  when  recent,  but  later  on  leaving  a 
coppery  stain.  Violent  exercise,  as  in  running  or  dancing,  is  liable  to  hasten 
or  determine  the  eruption,  as  is  true  of  simple  roseola.  There  is  usually  no 
pain  or  other  premonitory  symptom  with  this  eruption,  although  such  symp- 
toms as  facial  neuralgia  or  severe  pain  in  the  chest  may  be  observed,  and 
in  some  cases  general  malaise,  headache,  and  febrile  movement  may  occur, 
these  symptoms  being  supposed  by  some  to  be  constant,  and  hence  termed 
"syphilitic  fever."  The  author  has  recently  had  a  case  in  which  severe 
facial  neuralgia  attended  the  roseola,  and  another  in  which  all  the  sub- 
jective symptoms  of  an  impending  pneumonia  were  present,  the  thoracic 
pain  being  especially  severe,  these  symptoms  being  followed  by  a  classic 
roseola  the  next  morning.  In  still  another  case  systemic  disturbance  was 
ushered  in  by  severe  lumbar  pain  simulating  lumbago.  Sometimes  the 
roseolous  eruption  consists  of  but  a  few  pale  spots,  while  in  other  instances 
it  is  general  and  well  marked,  being  occasionally  slightly  elevated. 

The  notion  prevails  quite  generally  that  the  syphilitic  roseola  is  the 
result  of  local  changes  in  the  skin  produced  by  the  syphilitic  poison,  and, 
reasoning  a  priori  from  the  line  of  argument  already  presented,  the  natural 
conclusion  would  be  that  the  eruption  is  due  to  a  localized  cell-accumula- 
tion, the  products  of  which,  collecting  in  the  skin  itself,  constitute  the  ex- 
anthem.  This  is  not  the  case,  however,  and  it  is  the  only  instance  of  the 
kind  throughout  the  course  of  syphilis.  The  syphilitic  roseola  is  due  to 
dilation  of  the  cutaneous  capillaries,  with  subsequent  stasis,  and  the  ex- 
udation of  leucocytes  and  red  blood-corpuscles  into  the  implicated  integ- 
umentary area.^  The  greater  the  degree  of  stasis,  the  larger  the  number  of 
extravasated  red  corpuscles;  and  inasmuch  as  the  staining  of  the  tissues  is 
due  to  changes  in  the  blood-pigment,  the  greater  the  number  of  blood-cor- 
puscles extravasated,  the  deeper  and  more  persistent  this  staining  is  likely 
to  be.  A  similar  staining  is  met  with  in  any  lesion,  specific  or  simple,  in 
which  there  has  been  long-continued  congestion.  This  is  illustrated  by 
the  changes  in  the  superficial  tissues  resulting  from  non-syphilitic  ulcers 
of  the  leg.  It  now  remains  to  consider  the  origin  of  this  capillary  dilation, 
and  inasmuch  as  the  contractility  of  the  blood-vessels  is  presided  over  by 
the  sympathetic  system,  or  more  properly  by  the  vasomotor  fibers  of  the 
sympathetic,  it  is  evident  that  vascular  dilation  in  syphilis  must  be  due 
to  some  peculiar  influence  wrought  upon  the  sympathetic  system  by  the 

^  Biiumler. 


SYPHILITIC    PEODEOMES.  381 

syphilitic  infection  that  causes  a  suspension  of  the  contractile  power  of 
the  vascular  walls  and  leads  to  dilation  and  stasis  at  the  periphery.  That 
the  caliber  of  the  capillaries  depends  upon  nervous  currents  from  the  sym- 
pathetic is  illustrated  by  the  familiar  physiologic  demonstration  of  section 
of  the  cervical  sympathetic  causing  reddening  and  turgescence  of  the  ear 
and  various  nutritive  changes  in  the  cornea  of  the  rabbit,  etc.  It  is  pos- 
sible that  the  dilation  and  stasis  are  reflex  phenomena  due  to  reflected 
local  irritation  produced  by  the  syphilitic  infection  or  to  a  direct  influence 
of  the  infection  upon  the  vascular  walls;  but  this  explanation  is  hardly  so 
rational  as  that  involving  a  direct  influence  upon  the  sympathetic  centers 
analogous  to  that  produced  by  quinin,  belladonna^,  and  various  other  drugs 
and  by  emotional  disturbances.  In  the  light  of  our  recent  knowledge  of 
germ-infection  and  germ-products  the  author  feels  justified  in  the  belief 
that  the  disturbing  element  in  the  action  of  syphilis  on  the  sympathetic  is 
a  toxin  or  toxins  elaborated  by  the  syphilitic  micro-organism. 

Analogic  reasoning  is  not  always  satisfactory,  but  in  this  instance  the 
analogy  furnished  by  the  untoward  effects  of  drug  and  other  toxic  erup- 
tions appeals  to  one's  sense  of  clinical  discrimination  most  strongly. 
Apropos  of  toxin  eruptions,  attention  may  be  called  to  the  form  that  some- 
times appears  in  diphtheria — not  the  so-called  scarlatinoid,  in  which  a 
mistake  in  diagnosis  and  mixed  infection  are  both  possible,  but  the  later 
type  that  heralds  approaching  dissolution.  This  is  often  a  very  fair  imita- 
tion of  the  syphilitic  roseola. 

Syphilitic  Peodeomes. — Syphilitic  Fever. — Something  has  already 
been  said  in  reference  to  the  so-called  syphilitic  fever.  Among  the  phenom- 
ena that  may  be  observed  prior  to  the  development  of  the  roseola  are  malaise, 
headache,  rheumatoid  pains,  anorexia,  nausea,  prostration,  sleeplessness  and 
nervous  irritability,  and  in  some  cases  quite  sharp  febrile  movement,  per- 
haps followed  by  j^erspiration.  These  are  the  symptoms  several  or  all  of 
which  have  been  included  under  the  head  of  syphilitic  fever,  or,  as  Diday 
more  correctly  terms  them,  "syphilitic  prodromes."  On  reviewing  the  list 
of  single  symptoms  that  may  occur  it  is  evident  that  they  may  be  dependent 
upon  so  many  and  various  coincident  disturbances  that  there  can  be  no  great 
constancy  or  certainty  about  their  occurrence  in  syphilis.  The  term  sj^ph- 
ilitic  fever  is  therefore  obviously  inaccurate.  Eicord  denies  its  relation  to 
syphilis,  and  claims  that  in  every  case  it  can  be  traced  to  causes  independent, 
of  the  roseola.  Otis  indorses  this  view.  Until  recent  years  the  author  was 
inclined  to  agree  with  Eicord's  view,  for  febrile  disturbance  is  apparently 
exceptional  and  patients  usually  discover  the  roseola  entirely  by  accident 
or  in  their  daily  examination  of  the  surface  of  the  body,  and  but  rarely 
have  the  slightest  objective  symptom  of  constitutional  disturbance.  Very 
often  the  roseola  escapes  the  patient's  observation  until  his  attention  is 
directed  to  it,  and  then  he  is  usually  much  astonished  that  he  should  feel 
perfectly  well  with  such  a  prominent  eruption.    Since  the  advent  of  a  more 


382  GEXEEAL    IXFECTIOX    OF    SYPHILIS. 

thorough  understanding  of  germ-infection  and  coincident  toxin  poisoning, 
however,  the  author  has  come  to  regard  many  symptoms  that  were  formerly 
attributable  to  coincidence  as  being  without  doubt  attributable  to  S3'philitic 
toxins,  this  being  especially  true  of  early  nervous  phenomena.  That  such 
symptoms  are  not  uniform  in  their  occurrence  suggests  the  possible  ex- 
planation of  (1)  idiosyncrasy;  (2)  variations  of  excretory  activity;  (3)  in- 
complete study  of  the  case — and  esjjecially  the  temperature — prior  to  the 
appearance  of  lesions  perceptible  to  the  patient. 

From  personal  observation  the  author  feels  warranted  in  presenting  the 
following  conclusions:  1.  Syphilitic  fever,  so  called,  while  an  inconstant 
objective  phenomenon — or  series  of  phenomena — is  present  in  a  sufficient 
number  of  cases  of  syphilis  to  ^Dractically  settle  the  question  of  the  relation 
of  cause  and  effect.  2.  The  symj^toms  collectively  designated  as  syphilitic 
fever  are,  in  common  with  some  other  febrile  constitutional  disturbances, 
undoubtedly  dependent  upon  the  action  of  a  special  poison — a  germ  or  its 
toxins — upon  the  sympathetic  nervous  system.  3.  It  is  logical  to  infer  from 
Avhat  we  know  of  the  physiology  of  the  sympathetic  system,  and  particularly 
of  those  functions  of  the  sympathetic  which  we  term  trophic,  that  the  ma- 
jority of  fevers — if  not  all — are  directly  dependent  upon  the  action  of  the 
particular  specific  poison  upon  the  S3an23athetic  ganglia,  Avhich  action  is 
manifested  by  disturbed  metabolism  and  the  resulting  phenomena  of  fever. 
So,  in  the  case  of  syphilis,  the  poison  may  produce  such  a  profound  im- 
pression upon  the  sympathetic  ganglia  that  the  trophic  function  of  this 
jjortion  of  the  nervous  system  is  disturbed,  with  (a)  an  attendant  perversion 
of  tissue-metabolism,  (b)  a  resultant  excessive  production  of  animal  heat, 
and  (c)  the  accumidation  in  the  system  of  the  toxic  products  of  perverted 
physiochemic  change  in  addition  to  germ-toxins.  4.  The  fact  that  the  so- 
called  syphilitic  fever  is  not  a  constant  phenomenon,  but  affects  only  a  cer- 
tain portion  of  individuals  attacked  by  syphilis,  is  explicable  upon  the 
ground  of  idios3mcrasy  or  defective  elimination,  or  both.  Its  inconstancy 
may  be  more  apparent  than  real.  Careful  study  might  show  prodromes — 
especially  fever — in  all  cases. 

The  argument  that  the  so-called  syphilitic  fever  is  the  result  of  an  im- 
pression produced  by  the  syphilitic  infection  upon  the  sympathetic  nervous 
S3'Stem  does  not  necessarily  impty — nor  is  it  intended  to  do  so — that  any 
particular  prodromal  s3'mptom  is  a  part  of  the  natural  course  of  the  dis- 
ease. On  the  contrar3%  the  author  believes  many  of  the  s3anptoms  to  be 
accidental  and  the  result  of  idiosyncrasy.  AYe  know  that  dift'erent  indi- 
viduals are  variously  affected  by  urticaria  or  erythema  upon  the  ingestion 
of  shell-fish,  this  result  being  especially  apt  to  follow  when  the  particular 
article  of  food  is  not  perfecth'  fresh  or  is  not  in  an  absolutely  healthy  con- 
dition when  taken  for  food.  Some  persons  are  seriously  affected  by  the  in- 
gestion of  certain  vegetables — particularly  if  partial  decomposition  has  oc- 
curred.    Canned  vegetables,  particidarly  tomatoes,  are  especially  liable  to 


PHAEYNGO-FALX'IAL    IXFILTEATIOX.  383 

impeachment  upon  this  gronnd.  If  it  is  fair  to  infer  that  hy  virtue  of 
idiosyncrasy  the  nervous  systems  of  certain  subjects  may  be  morbidly  im- 
pressed by  certain  food-substances  that  are  innocuous  to  the  majority  of  in- 
dividuals, it  is  certainly  logical  to  assume  that  in  the  case  of  so  powerful  an 
organic  poison  as  that  of  s3qohilis,  with  which  a  large  number  of  individuals 
are  inevitably  inoculated,  certain  special  and  exceptional  phenomena  might 
be  produced  in  some  persons.  As  already  suggested,  careful  study  of  a  large 
number  of  cases  might  show  that,  while  prodromal  symptoms  vary  in  degree 
and  kind,  they  are  present  in  all  cases. 

E elation  of  General  Adenopathij  to  the  Roseola. — With  the  roseola,  or 
shortly  after  it,  in  cases  in  which  glandular  symptoms  have  not  occurred 
prior  to  the  appearance  of  the  eruption,  general  enlargement  of  the  lym- 
phatic glands — general  adenopathy — occurs,  the  infection  at  this  time  not 
only  having  reached  the  general  15'mphatic  system,  which  is  extremely  sus- 
ceptible to  its  morbific  influence,  but  being,  moreover,  unusually  active. 

Pliaryngo-faucial  Infiltration. — About  the  time  the  roseola  appears, 
sometimes  shortly  before  or  after  it,  we  have  the  development  of  an  inflam- 
matory engorgement  of  the  tonsils,  pharynx,  and  soft  palate,  involving 
usually  the  whole  faucial  surface.  There  should  be  some  explanation  of 
this  localization  of  the  effects  of  syphilis  in  the  throat,  and  a  simple  one 
has  been  suggested  by  the  anatomic  peculiarities  of  the  part.  According 
to  Frey,  His,  Eeeklinghausen,  and  Teichmann,  the  tonsil  is  a  part  of  the 
general  lymphatic  system,  representing  the  simplest  form  of  13'mphatic 
gland.  There  is  no  direct  communication  between  the  tonsillar  follicles 
and  the  adjacent  Ijmiphatic  vessels,  but  each  follicle  is  seen  to  be  invested 
with  an  exceedingly  dense  net-work  of  fine  lymphatic  vessels,  that  are 
dilated  in  a  peculiar  fashion  and  cover  in  the  follicle  so  completely  that 
but  one  small  jJortion  of  its  surface  is  free,  this  being  directed  toward  the 
mucous  membrane.  The  entire  pharynx  is  exceedingly  rich  in  lymphatics, 
hence  morbid  changes  in  its  structures  might  naturally  be  expected  simul- 
taneously with  those  occurring  in  the  general  lymphatic  system.  This  ar- 
rangement of  the  lymphatics  also  explains  another  phenomenon,  viz.:  the 
occurrence  of  those  severe  and  often  seriously  destructive  ulcerations  ihat 
occur  in  this  situation  in  late  syphilis.  These  lymphatics  are  brought  into 
much  more  intimate  relations  with  the  contiguous  blood-vessels  than  are 
the  lymphatics  of  a  higher  order,  and  are  hence  prone  to  true  inflamma- 
tion and  profound  nutritive  disturbances  whenever  they  become  crowded 
with  syphilitic  cells. 

The  explanation  of  the  involvement  of  the  fauces  and  pharynx  char- 
acteristic of  secondary  syphilis,  upon  the  ground  of  lymphatic  engorgement, 
the  primary  cause  of  which  is  the  abundance  and  superficial  character  of 
the  lymphatic  capillaries  of  the  affected  parts,  is  quite  plausible.  It  is  a 
noteworthy  fact,  however,  that  there  is  but  little  swelling,  joain,  and  tender- 
ness accompanying  the  syphilitic  sore  throat,  providing  ulcers  be  absent. 


384  GEXEEAL    IXFECTIOX    OF    SYPHILIS. 

There  is  also  in  the  earl}'  part  of  the  disease  little  or  no  tendency  to  ulcera- 
tion in  the  majority  of  cases.  There  is  comparatively  little  heaping  np  of 
syphilitic  material  as  contrasted  with  some  other  lesions, — the  papule,  for 
example.  These  characters  suggest  that  there  is  something  behind  the  local- 
ized proliferation  of  cells— something  too,  that  will  explain  the  appearance 
of  morbid  phenomena  at  this  particular  point  aside  from  mere  anatomic 
peculiarities.  For  obvious  reasons  it  has  not  been  shown  that  the  same 
efflorescence  and  engorgement  does  not  occur  throughout  the  entire  alimen- 
tary canal  in  early  syphilis.  Admitting  that  there  is  a  diffuse  accumulation 
of  cells  in  the  pharyngo-faucial  tissues,  there  should  be  something  more 
than  local  anatomic  peculiarities  to  explain  it.  May  it  not  be  a  result  of 
vasomotor  changes  similar  to  those  prevailing  in  the  roseola,  due  to  the  im- 
pression of  the  S3^philitic  infection  upon  the  central  nervous  system?  The 
same  condition,  possibly,  prevails  in  other  portions  of  the  alimentary  tract, 
which  are,  as  is  well  known,  intimately  associated  with  the  sympathetic 
nervous  system.  It  is  only  at  this  point,  however,  that  the  parts  affected 
are  so  superficial  as  to  be  open  to  observation.  At  this  point,  moreover, 
causes  of  irritation  are  more  prevalent  than  in  other  portions  of  the  ali- 
mentary tract.  The  food  that  is  swallowed,  rapid  changes  of  temperature 
incidental  to  respiration  or  the  ingestion  of  fluids  at  various  temperatures, 
the  use  of  the  voice,  the  contact  of  irritating  secretions  from  the  nose, 
and  the  inhalation  of  irritating  substances  from  the  atmosphere  must 
certainly  assist  in  localizing  the  syphilitic  process  in  the  throat.  In  the 
presence  of  such  local  causes  of  irritation  vasomotor  disturbance  incidental 
to  the  impression  of  the  syphilitic  poison  upon  the  central  nervous  system 
might  be  determined  at  this  point,  even  though  absent  elsewhere. 

As  will  be  seen  presenth',  the  vasomotor  impression  underlying  the 
roseola  is  substituted  later  on  by  a  more  or  less  pronounced  trophic  disturb- 
ance, manifested  by  the  heaping  up  of  neoplastic  material,  the  development 
of  pus,  the  occurrence  of  ulcerations,  etc.  Pari  passu  with  the  supervention 
of  this  trophic  disturbance  in  the  case  of  the  skin  we  have  a  similar  state 
of  affairs  in  the  pharynx  and  mucous  membrane  of  the  mouth,  as  mani- 
fested by  the  development  of  mucous  patches,  ulcers,  and  macular  erup- 
tions, the  latter  being  particularly  marked  upon  the  roof  of  the  mouth.  The 
apparent  affinity  of  syphilis  for  the  parts  supplied  by  the  fifth  nerve  will 
be  discussed  hereafter.  It  is  sufficient  to  remark  here  that  this  special  pre- 
dilection has  an  important  bearing  upon  pharyngeal  lesions. 

The  Papulae  Stphilide. — The  next  thing  observable  after  the  rose- . 
ola  in  the  typic  course  of  syphilis  is  the  development  of  an  eruption  of  true 
papules.  This  may  appear  when  a  roseola  has  not  been  noticed,  thus  seem- 
ing to  be  the  first  skin-lesion  of  the  disease,  or  may  even  be  coincident  with 
it,  but  generally  follows  it  after  a  variable  interval,  often  some  weeks  or 
months.  The  papules  are  usually  most  prominent  about  the  borders  of  the 
hair  upon  the  forehead,  forming  a  peculiar  appearance  termed  the  corona 


THE  PAPULAR  SYPHILIDE. 


385 


veneris  or  venereal  crown,  but  may  be  scantily  scattered  over  the  breast^ 
back,  and  limbs.  In  still,  other  instances  they  may  be  thickly  studded  all 
over  the  body.  This  eruption  lasts  longer  than  the  roseola,  occasionally 
remaining  prominent  for  a  number  of  months.  It  is  at  first  of  a  tolerably 
bright-reddish  hue,  but  this  gradually  fades,  leaving  the  characteristic  ham 
color.  The  papules  tend  to  exfoliate  epithelial  scales,  especially  at  their 
bases,  forming  a  peculiar  appearance  known  as  the  collarette  of  Biette,  a 
sign  that  is  supposed  by  some  to  be 
pathognomonic  of  syphilis.  It  is  un- 
doubtedly characteristic  when  present, 
but  unfortunately  it  is  oftener  absent. 
This  shedding  of  epithelial  cells  around 
the  base  of  the  papule  of  syphilis  is  due 
simi^ly  to  innutrition  of  the  epithelial 
elements  about  the  base  of  the  papule 
produced  by  the  heaped-up  morbid  cells 
within  it.  This  process  is  precisely  like 
that  which  causes  loss  of  tissue  in 
the  initial  lesion,  viz.:  necrobiosis,  or 
anemia  of  tissue,  from  the  pressure  of 
abnormal  cell-infiltration. 

According  to  Kohn,  the  papule  is 
composed  of  a  dense,  circumscribed, 
cellular  infiltration  into  the  papillae 
and  corium.  This  accumulation  of 
cells  is  piled  up  in  dense,  regular  layers 
around  the  vessels,  and  in  the  meshes 
of  the  connective  tissue.  These  cells 
do  not  become  permanently  organized, 
but  tend  to  undergo  granular  and  fatty 
degeneration  and  finally  disappear 
entirely,  as  a  rule,  the  detritus  pro- 
duced by  their  retrograde  metamorpho- 
sis being  removed  by  the  absorbents  to 
be  eliminated  by  the  various  emunc- 
tories.  Or  the  cells  may  become  heaped 
together    in    large    amount    and    form 

pus — which  will  certainly  form  if  the  morbific  material  becomes  secondarily 
infected  with  pus-cocci.  On  section  of  the  papule  we  find  two  lines  of  cells 
in  the  corium  and  papillary  layer  of  the  derma,  which  layers  are  glued  to- 
gether quite  firmly,  the  epidermis  being  tightly  stretched  over  them.  The 
hardness  of  the  papule  is  due  to  the  density  and  dryness  of  the  accumulated 
cells,  and  its  color  to  capillary  stasis,  effusion  of  coloring  matter  from  the 
blood-vessels,  and  possibly  to  the  color  of  the  neoplasm  itself.     It  will  be 


Fig.  105. — Papular  syphilide. 
(After  Keyes.) 


386 


C4EXEEAL    IXFECTIOX    OF    SYPHILIS. 


noted  that  the  structure  of  a  secondary  papule  is  essentially  that  of  the  ini- 
tial lesion  and  the  primary  glandular  infiltration.  .  It  now  remains  to  explain 
the  cause  of  the  circumscribed  collection  of  cells  constituting  the  S3'philitic 
papule. 

"We  have  already  seen  that  the  initial  lesion  is  due  to  an  accumulation 

of   cells,   which   results   from   a 

ST ~ —        1      morbid    impulse    given    to    the 

normal  leucocytes  in  loco  by  the 
syphilitic  infection,  and  it  would 
seem  a  very  logical  inference 
that  there  exists  in  the  papule 
a  similar  process,  and  such  is 
really  the  case.  It  seems  pecul- 
iar that  these  cell-accumulations 
occur  in  the  papilljEe  and  cutis 
rather  than  in  other  situations. 
However,  by  reviewing  the 
anatomy  and  physiology  of  the 
skin  a  little,  it  is  not  difficult  of 
explanation.  The  blood  con- 
taining the  nutrient  pabulum 
upon  which  the  repair  of  the 
tissues  depends  is  distributed 
to  the  various  tissues  of  the 
body  by  the  arteries,  and  re- 
turns loaded  with  the  products 
of  retrograde  tissue-metamor- 
phosis by  way  of  the  veins. 
There  must,  of  necessity,  be  a 
certain  amount  of  nutritive  or 
germinal  material  taken  to  the 
tissues,  over  and  above  the 
quantity  necessary  for  their  re- 
pair, and  there  should  be  some 
physiologic  means  of  restoring 
this  to  the  blood.  Such  an 
arrangement  does,  in  fact,  ex- 
ist. Interposed  between  the 
arterial  and  venous  systems 
there  is  a  system  of  fine  vessels,  the  lymphatics,  the  function  of  which  is  to 
collect  all  surplus  germinal  material  and  return  it  to  the  circulation.  The 
nearest  points  of  contact  of  the  arterial,  venous,  and  lymphatic  vessels  are 
at  the  superficies, — i.e.,  the  periphery  of  the  body, — where  the  capillaries  of 
the  general  circulatory  and  lymphatic  systems  are  in  most  intimate  relation. 


Ym.  106. 


-Papulo-squaiiiuu^ 
(After  Fox.) 


-ypii 


ilide. 


THE    PAPULAR    SYPHILIDE. 


387 


As  it  is  here  that  the  vessels  are  smallest,  it  is  naturally  in  this  situation 
that  retardation  of  the  circulation  is  most  likely  to  occur,  or  an  interference 
with  the  interchange  of  nutritive  materials  results  from  exciting  causes  of 


Fig.    107. — Pustulo-ulcerous   syphilicle.      (After    Dumesiiil.) 


various  kinds.  It  is  here,  therefore,  that  we  sliould  expect  to  find  collections 
of  surplus  germinal  material  which  from  any  cause  have  been  forced  to 
accumulate  in  the  tissues  and  have  failed  to  find  an  entrance  into  the  lym- 


388  GEXEEAL    IXFECTIOX    OF    SYPHILIS. 

phatics.  The  structure  of  the  papillEe  of  the  cutis  contains  lymi^hatic  capil- 
laries and  blood-Yessels.  According  to  v.  Rindfieish,  Teichmann,  and  others_, 
the  lymphatic  plexus  lies  in  the  center  of  the  papilla,  while  the  capillary 
blood-vessels  wind  around  it,  corkscrew  fashion,  until  they  reach  the  apex. 
Teichmann,  in  particular,  has  called  attention  to  this  peculiar  arrangement 
These  vessels  vary  in  size  from  time  to  time,  and  vary  according  to  the 
degree  of  vascular  or  hlood-  pressure.  It  is  in  the  spaces  between  these  capil- 
lary loops  and  the  central  lymphatics  that  the  accumulation  of  cells  in  the 
syphilitic  papule  takes  place.  x\n  extra  number  of  cells  is  brought  to  the 
part,  and,  in  addition,  there  is  an  increased  local  proliferation  that  tempo- 
rarily blocks  up  the  lymphatics  or  overcomes  their  power  to  dispose  of  sur- 
plus germinal  material.  The  result  is  a  heaping  up  of  cells,  with  all  those 
attendant  morbid  phenomena  that  have  been  studied  in  the  initial  lesion. 
Sometimes  the  papules  are  very  fine,  but  the}^  may  become  large,  sometimes 
by  fusion.  They  may  involve  sebaceous  and  sudoriparous  glands, — which 
have  no  lymphatics — simply  matting  them  into  the  general  infiltration  of  a 
number  of  papillae. 

Otis,  following  Besiadecki  and  others,  has  claimed  that  the  evident 
predilection  of  syphilitic  material  for  the  papillse  of  the  skin  is  due  to 
the  mechanic  fact  that — on  account  of  the  peculiar  arrangement  of  their 
arterial,  venous,  and  intervening  lymphatic  capillaries,  already  described — 
it  is  in  the  papillse  of  the  skin  that  the  narrowest  points  in  the  circulatory 
and  lymphatic  flow  are  to  be  found.  The  affinity  of  the  syphilitic  process 
for  lymphatic  structures  explains  the  rest,  and,  as  we  have  seen,  there  occurs 
at  various  points  in  the  superficies  of  the  body  a  localized  heaping  up  of 
syphilitic  cells.  The  roseola,  however,  as  already  stated,  consists  of  localized 
and  circumscribed  jDhenomena  that  are  not  satisfactorily  explicable  upon 
mechanico-anatomic  grounds.  Why  does  not  the  roseola  appear  in  one  con- 
tinuous blush  over  the  entire  surface  of  the  body?  Is  it  not  because  the 
impression  of  the  syphilitic  infection  upon  the  system  is  manifested  through 
a  vasomotor  dieturbance  of  the  function  of  the  sympathetic  ganglia  at 
certain  terminals  in  the  skin?  Otis  accepts  the  neurotic  origin  of  the 
roseola,  and  it  is  a  matter  of  surprise  that  he  should  seek  for  local  anatomic 
conditions,  determinative  of  the  syphilitic  process  in  the  papillge  of  the  skin, 
as  a  cause  for  the  development  of  the  syphilitic  papule.  In  view  of  the  prob- 
able explanation  of  the  roseola,  would  it  not  be  fair  to  infer  that  a  similar 
condition  of  affairs  prevails  in  the  case  of  other  eruptions — i.e.,  that,  as  a 
consequence  of  an  impression  made  by  the  syphilitic  infection  upon  the 
sympathetic  ganglia,  their  trophic  functions  are  disturbed,  with  consequent 
disturbance  of  nutrition  and  perverted  tissue-building  at  certain  points 
upon  the  periphery  or  superficies  of  the  body?  The  local  anatomic  arrange- 
ment would  explain  the  rest.  This  hypothesis  is  at  least  worthy  of  thought 
as  a  possible  logical  explanation  of  the  phenomena  of  syphilis.  It  would 
be  particularly  satisfactory  if  demonstrated  to  be  true,  for  it  covers  not  only 


TROPHIC    CHARACTER    OF    SKIX-LESIOXS.  389 

the  roseola  and  papule,  but  every  other  lesion  that  may  occur  throughout 
the  entire  course  of  syphilis. 

The  lesions  of  syphilis  that  succeed  the  roseola  have  been  so  posi- 
tively demonstrated  to  be  dependent  upon  a  localized  deposit  and  prolifera- 
tion of  syphilized  cell-material  that  it  would  appear  at  first  sight  to  be  im- 
possible to  apply  the  neurotic  theory  to  them.  It  is  only  necessar}',  how- 
ever, to  direct  attention  to  the  marked  symmetry  characterizing  the  periph- 
eral phenomena  of  syphilis  to  demonstrate  the  plausibility  of  the  view  that 
there  is  a  central  nervous  element  in  the  production  of  the  various  lesions. 
It  is,  of  course,  admitted  that  a  symmetric  development  of  eruptive  lesions 
occurs  in  some  other  affections.  It  will  be  found,  however,  that  a  nervous 
element  is  either  positively  demonstrable  or  the  skin-lesions  are  so  abundant 
and  general  that  it  would  be  impossible  that  they  should  be  otherwise  than 
symmetric. 

A  most  positive  proof  of  the  relation  of  eruptions  of  the  skin  to  nervous 
disturbance  of  a  presumably-trophic  character  is  seen  in  herpes  zoster.  In 
this  disease  there  is  a  fairly  accurate  delineation  of  the  course  of  the 
affected  nerve  by  the  eruption,  and  a  very  manifest  local  disturbance  of 
nutrition  of  the  affected  tissues.  Generally  some  portion  of  but  one  side 
of  the  body  is  affected  by  this  disease.  It  is  sometimes  bilateral  and  con- 
sequently of  a  more  serious  character  than  usual.  Some  of  the  later  lesions 
of  syphilis  are  unilateral  and  almost  as  plainly  referable  to  the  distribution 
of  some  particular  nerve  as  herpes  zoster. 

Recurrent  herpes  zoster  is  especially  pertinent  to  the  question  of  tropho- 
neurosis. This  disease  is  usually  followed  by  cicatrices.  The  first  symptom 
is  a  burning  sensation  followed  by  severe  neuralgic  pains.  Injury  is  often 
the  exciting  cause  and  it  is  frequently  bilateral.  Herpes  progenitalis  is 
often  the  result  of  syphilis, — being  moreover  a  pure  neurosis,  due,  first,  to 
syphilis;  second,  to  worry;  third,  to  overactive  therapeusis.  These  causes 
bring  about  disturbed  innervation  and  nutritive  disorder. 

It  will  be  understood  that  the  view  that  neurosis  is  a  very  important 
factor  in  the  lesions  of  active  syphilis  in  nowise  contradicts  the  cellular 
pathology  so  far  as  its  local  phenomena  are  concerned.  It  has  to  do  merely 
with  the  modus  operandi  by  which  these  phenomena  are  brought  about. 
The  question  is  simply  whether  the  various  phenomena  have  their  point  of 
departure  in  an  infection  acting  in  loco  or  in  local  changes  of  a  central 
neuropathic  origin,  the  infection  acting  in  some  manner  upon  the  sympa- 
thetic and,  by  disturbing  its  trophic  function,  exciting  a  morbid  process  of 
cell-accumulation  in  the  superficies  of  the  body. 

Syphilitic  Alopecia. — During  the  period  of  general  syphilis,  usually 
during  the  early  months  of  the  secondary  period,  often  co-existent  with  the 
papular  eruption,  falling  of  the  hair,  or  alopecia,  occurs.  This  results  from 
derangement  of  nutrition  in  the  hair-follicles. 

This  lesion  of  early  syphilis  especially  appeals  to  the  author  as  a  syph- 


390  GENERAL    INFECTION    OF    SYPHILIS. 

ilitic  neurosis:  a  trophoneurosis,  in  brief.  Tliis  may  be  dangerous  ground, 
for  the  close  association  of  alopecia  with  tangible  cell-deposit  in  other  situ- 
ations has  led  to  the  tacit  acceptance  of  this  lesion  as  an  evidence  of  the 
action  of  the  materies  morhi  of  syphilis  in  loco.  Some  authorities  believe  it 
to  be  due  to  local  empoisonment  of  the  hair-follicle  with  resultant  nutritive 
perversion.    ' 

Otis,  following  Baumler,  and  Besiadecki,  thinks  that  alopecia  sypli- 
ilitica  is  due  to  pressure-innutrition  of  the  hair-follicles  produced  b}''  an  ac- 
cumulation of  syphilized  cell-material,  cure  being  induced  by  spontaneous 
or  therapeutically-induced  fatty  degeneration  and  absorption  of  the  infil- 
trated cells.  The  author  himself  long  taught  this  view.  Further  study  has 
brought  conviction  of  its  fallacy.  The  following  considerations  are  impor- 
tant in  this  connection: — • 

1.  Lesions  of  the  scalp  of  sufficient  prominence  to  attract  attention  are 
rather  exceptional  in  syphilitic  alopecia,  a  few  scattered  papules  and  accumu- 
lations of  epidermal  cells  or  sebum  being  found  in  a  certain  proportion  of 
cases.  2.  Scarring  is  rare,  and  when  it  does  occur  permanent  l^aldness  of 
the  affected  area  results,  as  a  rule.  3.  Tertiary  syphilis,  in  which  cell- 
accumulation  is  most  marked,  is  rarely  causative  of  characteristic  alopecia. 
4.  Severe  alopecia,  not  only  areate  but  generalized,  may  occur  without  any 
other  lesion — accompanying,  preceding,  or  following.  This  could  hardly 
occur  if  the  alopecia  were  due  to  cell-deposit,  inasmuch  as  in  the  early 
secondary  period,  when  alopecia  is  most  often  found,  the  tendency  to  cell- 
deposit  is  quite  generalized.  Taking  all  the  facts  into  consideration,  the 
author  has  become  convinced  that  syphilitic  alopecia  is  a  neurosis. 

If  the  mechanic  theory  be  correct,  it  is  strange  that  lesions  of  the  scalp 
of  sufficient  prominence  to  attract  attention,  are  so  rarely  associated  with 
alopecia.  A  few  small  papules,  pustules,  and  crusts  are  occasionally  found, 
but  hardly  ever  in  sufficient  amount  to  account  for  the  extensive  falling  of 
the  hair.  It  will,  of  course,  be  found  that  at  the  site  of  such  lesions  the 
hair  invariably  falls  out.  It  would  seem  that  if  the  syphilitic  material  had 
such  an  affinity  for  the  scalp  as  would  be  indicated  by  the  theory  of  localized 
cell-deposit,  the  cutaneous  lesions  of  this  portion  of  the  integumentary  sur- 
face should  be  especially  pronounced.  It  is  hardly  probable  that  in  the 
■presence  of  such  an  affinity  for  the  hair-follicles,  a  deposit  of  syphilitic  ma- 
terial would  accumulate  to  such  an  extent  as  would  be  sufficient  to  deprive 
the  hair-follicle  of  nutrition  and  yet  fall  short  of  a  sufficient  amount  to  be 
perceptible  externally.  It  is  true  that  more  or  less  accumulation  of  germinal 
material  in  the  hair-follicles  may  occur,  but  it  certainly  cannot  be  sufficient 
to  account  for  the  alopecia,  and  there  still  remains  the  necessity  for  an 
explanation  of  its  deposition  in  this  location. 

Reasoning  by  analogy,  we  find  much  support  for  the  neurotic  theory  of 
alopecia.  The  effects  of  fright,  fevers,  and  head-neuralgias  on  the  color 
and  nutrition  of  the  hair  are  well  known.    Leloir,  Dumesnil.  and  others  have 


SYPHILITIC    ALOPECIA.  391 

cited  cases  where  traumatism  of  the  sympathetic  has  jjrodiiced  alojDecia. 
Joseph's  experiments  are  quite  significant  in  this  connection.  He  divided 
the  spinal  ganglion  of  the  second  cervical  nerve  in  cats  and  thereby  pro- 
duced baldness. 

As  a  further  illustration  of  the  relation  of  malnutrition,  probably 
dependent  upon  perversion  of  the  functions  of  the  sympathetic  nervous 
system,  to  falling  of  the  hair,  may  be  mentioned  the  alopecia  resulting  from 
the  excessive  use  of  arsenic  internally. 

The  relative  immunity  that  the  beard  of  the  male  enjoys  as  compared 
with  the  hair  of  the  scalp  is  probably  dependent  upon  the  greater  intrinsic 
strength  of  the  facial  hair-growth  and  the  higher  vascularity  of  the  face. 

Accepting  the  neuropathic  character  of  the  syphilitic  roseola  and  alo- 
pecia, these  lesions  are  very  suggestive.  If  they  are  due  to  disturbance  of 
the  sympathetic  we  have  only  to  imagiiie  similar  vasomotor  and  tropho- 
neurotic changes  in  the  central  and  peripheral  nervous  structures  to  get  a 
tolerably  clear  idea  of  more  serious  neuroses  in  early  syphilis.  The  origin 
of  the  scalp  neurosis  under  consideration  is  not  far  to  seek.  It  is,  without 
much  doubt,  toxins  resulting  from  the  evolution  of  the  syphilitic  microbe. 

Syphilis  of  the  Nails. — The  nails  of  the  fingers  and  toes  may  become 
affected  by  the  sjqDhilitic  cellular  infiltration  and  become  brittle  and  luster- 
less,  or  from  very  great  infiltration  and  consequent  nutritive  disturbances — 
and  perhaps  secondary  pus-infection — the  destructive  lesion  known  as  syph- 
ilitic onychia  may  occur.    -     , 

Precocious  Skin-lesions. — As  already  stated,  pustules^ or  vesicles  may 
form  during  the  papular  stage  of  syphilis.  Ulcerations  resembling  tertiary 
or  late  secondary  lesions  may  also  occur.  These  constitute  precocious  syph- 
ilis. These  changes  apparently  result  from  a  lack  of  formative  power  in  the 
lymph  or  a  tendency  to  liquefaction  of  the  hyperplasic  materials,  due  to 
constitutional  debility  or  lack  of  tone.  Profound  syphilitic  toxemia  may 
have  much  to  do  with  these  cases. 

Special  Mucous  Lesiojis. — There  are  several  peculiar  lesions  occurring 
during  the  period  of  general  syphilis  that  are  both  important  and  inter- 
esting, but  which  are  really  mere  modifications  of  the  syphilitic  papule,  de- 
pendent mainly  upon  their  situation  and  surroundings.  Mucous  patches 
upon  the  various  mucous  surfaces  or  quasimucous  surfaces,  where  they  are 
constantly  subjected  to  irritation  from  friction,  heat,  and  moisture,  are 
examples.  These  lesions  are  elevated  plaques  of  a  milky  or  grayish  color, 
covered  with  a  grayish  exudate  and  are  not  greatly  unlike  the  primary  super- 
ficial erosion  sometimes  seen  upon  the  genitals.  When  situated  about  the 
anus,  upon  the  scrotum,  vulva,  or  between  the  digits,  these  plaques  muqueuse 
tend  to  become  hjqDertro^jhied,  forming  broad  papules  or  excrescences  more 
or  less  elevated,  sometimes  covered  with  a  quasidiphtheritic  deposit,  and 
usually  secreting  a  foul-smelling  serous  secretion.  These  modified  mucous 
patches  are  termed  mucous  tubercles,  or  condylomata.    The  existence  of  local 


392  CtEXEEAL   IISfFECTION    OF    SYPHILIS. 

irritation  often  determines  the  development  of  miicons  patches,  as  is  seen 
in  the  month  from  the  contact  of  a  pipe-stem  or  from  irritation  of  the 
mucons  membrane  of  the  mouth  or  tongue  by  a  broken  tooth.  Tobacco- 
smoke  from  either  pipe  or  cigars  and  tobacco-juice  will  also  produce  milky- 
hued  patches — plaqu&s  opalines- — and  it  will  be  much  easier  to  prevent  them 
by  removing  sources  of  local  irritation  than  to  remove  them  when  formed. 

Xon-syphilitic  persons  who  smoke  to  excess  are  sometimes  affected  by 
a  slow,  chronic  inflammation  of  the  mucous  membrane,  with  resultant 
whitish  patches  upon  the  cheeks,  lips,  and  tongue,  strongly  resembling  the 
mucous  patch.  This  affection  is  completely  curable  by  cutting  off  the  source 
of  irritation.  Vidal  has  described  a  simple,  non-syphilitic  affection  of  the 
tongue  that  may  be  mistaken  for  syphilis.  This  he  terms  buccal,  or  lingual, 
leucoplasia.  It  consists  of  an  epithelial  thickening  followed  by  papilloma- 
tous hypertrophy,  and  perhaps  ulceration  with  consequent  cicatrization. 
The  spots  of  thickened  epithelium  resemble  those  caused  by  nitrate  of  silver, 
and  may  be  detached  in  flakes.  Post-syphilitic  leucoplasia  will  be  discussed 
later. 

Caspary,  Unna,  Parrott,  and  more  recently  Hack  have  called  attention 
to  a  condition  of  excoriation  of  the  tongue,  superficial  in  character  and  char- 
acterized by  deficiency  of  the  normal  papillae.  This  is  independent  of  syph- 
ilis, is  hereditary  in  origin,  and  has  been  traced  by  Hack  through  three 
generations  in  two  different  families.  The  possible  occurrence  of  this  con- 
dition is  to  be  borne  in  mind.  In  the  author's  experience  congenital  aber- 
rations of  papillary  and  epithelial  growth  affecting  the  lingual  mucosa  are 
by  no  means  rare.  Papillary  hypertrophy  of  congenital  origin  is  especially 
frequent. 

Visceral  Involvement. — Visceral  engorgements  and  infiltrations  are  by 
no  means  uncommon  in  syphilis,  congestion  characterizing  the  early 
secondary,  diffuse  infiltration  the  late  secondary,  and  distinct  gummy  de- 
posit the  sequelar  period.  Tenderness  over  the  liver,  spleen,  and  kidneys 
is  occasionally  observed.  Transient  albuminuria  is  not  uncommon.  Care 
is  necessary  to  determine  whether  the  disease  or  the  treatment  is  re- 
sponsible for  the  albuminuria  in  each  particular  case.  The  author  has 
long  entertained  the  view  that  more  or  less  transitory  circulatory  disturb- 
ance of  the  viscera  is  quite  a  constant  feature  of  early  syphilis.  That 
this  is  due  in  early  cases  in  any  great  degree  to  cell-deposit  is  doubtful; 
there  is  too  little  disturbance  of  function,  as  a  rule.  It  would  appear  logical 
to  infer  that  certain  visceral  areas  are  the  seat  of  changes  similar  to  those 
characterizing  the  roseola,  at  which  time  no  cell-deposit  may  be  manifest  in 
any  location.  If  the  author's  position  be  correct  regarding  the  presence  of  a 
sympathetic  neurosis  produced  by  syphilitic  toxins  at  this  period,  the  vis- 
cera, bearing  as  they  do  so  important  a  relation  to  the  sympathetic,  could 
hardh^  be  expected  to  escape.  As  already  remarked,  there  is  usually  no 
marked  disturbance  of  function  in  early  syphilis,  but  some  striking  excep- 


INVOLVEMENT    OF    SPECIAL    TISSUES   AND    ORGANS.  393 

tions  to  this  rule  are  met  with.  For  example,  the  author  has  seen  severe 
Jaundice  apparently  due  to  hepatic  involvement  at  a  very  early  period  of 
the  disease.  Albuminuria  in  early  syphilis  is,  perhaps,  like  the  nephritic 
disturbances  of  other  infectious  diseases:  the  effect  of  the  direct  action  of 
toxins  upon  the  renal  epithelium.  It  is  to  he  remembered  that  the  later 
visceral  disturbances  are  likely  to  be  due  to  a  diffuse  syphilomatous  infiltra- 
tion, which,  organizing  and  contracting,  may  seriously  impair  the  structural 
integrity  of  the  organ.    This  is  especially  noticeable  in  the  liver  and  kidney. 

Hutchinson  admits  that  the  early  lung  involvement  of  syphilis  consists 
of  temporary  congestions,  actual  inflammations  and  infiltrations  being  re- 
served for  a  later  stage.  Aside  from  the  possible  existence  of  pulmonary 
vasomotor  disturbance  as  the  explanation  of  such  phenomena,  it  is  not  be- 
yond the  bounds  of  probability  that  in  such  cases  the  syphilitic  toxins  act 
in  some  peculiar  manner  upon  the  pneumogastric. 

Early  Ocular  Syphilis. — During  the  active  period  we  often  have  ocular 
troubles  that  may  prove  of  very  serious  import.  An  infiltration  of  cells  into 
the  iris  and  ciliary  body  often  sets  up  an  iritis  at  this  time,  this  inflamma- 
tion being  really  in  no  way  distinguishable  from  that  produced  in  the  same 
situation  by  rheumatism,  trauma,  or  other  exciting  causes.  There  is,  per- 
haps, a  greater  tendency  to  chronicity  and  plastic  exudate  with  the  forma- 
tion of  adhesions  or  synechias,  and  the  iris  is  possibly  a  trifle  more  cloudy 
and  infiltrated  than  in  the  simple  forms  of  iritis;  but  the  differences,  if  any 
exist,  are  too  slight,  as  a  general  rule,  to  be  of  very  great  practical  impor- 
tance from  a  diagnostic  stand-point.  It  has  been  claimed  that  iritis  gener- 
ally occurs  in  both  eyes  (in  60  per  cent,  of  cases)  and  that  it  passes  unno- 
ticed in  many  instances,  on  account  of  absence  of  pain.  This  may  be  true 
pathologically,  but  clinically  it  is  usually  monocular.  The  local  accumula- 
tion of  cells  in  these  cases  sometimes  forms  a  distinct  nodule  or  tumor,  often 
erroneously  termed  "gummy  tumor  of  the  iris,"  but  which  is  in  nowise 
different  in  structure  from  the  syphilitic  papule.  This  is  especially  apt  to 
occur  in  late  S3'philis,  in  which  event  it  may  perhaps  be  justly  styled  "gum- 
mous."     Similar  plastic  nodules  may  form  in  the  choroid  at  this  period. 

Early  Osseous  Symptoms. — Bone-pains,  usually  localized,  and  localized 
subperiosteal  accumulations  of  cells  termed  nodes  frequently  occur  during 
early  syphilis,  although  more  characteristic  of  late  syphilis.  The  pain  in 
these  instances  is  due  to  intra-osseous  or  subperiosteal  pressure  produced  by 
the  dense  accumulations  of  cells. 

Sufiicient  attention  has  now  been  given  to  the  pathology  of  active  or 
general  syphilis  to  give  a  tolerably  clear  idea  of  its  various  phenomena,  and 
to  demonstrate  one  imjoortant  point  an  acceptance  of  which  will  enable  the 
student  to  understand  syphilis  in  all  the  forms  and  varieties  of  its  patho- 
logic phenomena,  viz.:  With  few  exceptions,  the  pathologic  manifestations 
of  syphilis  occurring  during  the  active  period  of  the  disease  are  due  to  a 
localized  cell-accumulation  and  cell-proliferation,  and  to  nothing  else.     An 


394  GEXEEAL    IXFECTIOK    OF    SYPHILIS. 

intelligent  appreciation  of  this  fact  will  alone  form  a  rational  basis  for  the 
treatment  of  the  disease,  Avhich  is  alike  in  every  case  and  consists  simply 
of  all  those  means,  whether  general  or  local,  that  tend  to  produce  fatty  de- 
generation or  retrograde  metamorphosis  in  the  hyperjilasic  materials  and 
induce  their  elimination  from  the  body,  while  at  the  same  time  tending  to 
improve  the  general  health.  This  projjosition  is,  in  effect,  a  resume  of  syph- 
ilitic pathology.  The  only  distinguishing  characteristic  of  the  syphilitic 
cell  as  contrasted  with  the  normal  germinal  cell  is  its  contagiousness, — of 
jDrobable  germ-origin, — which  consists  in  its  power  of  imparting  to  normal 
leucocytes  its  own  tendency  to  proliferation.  This  rapid  proliferation  does 
not  usually  cause  destruction  of  tissue,  but  gives  rise  to  phenomena  which, 
a  priori,  we  might  expect  from  an  accumulation  of  surplus  nutritive  ma- 
terial. This  cell-accumulation  obstructs  the  tissues  for  a  time  in  uncom- 
plicated cases,  and  then,  from  prolonged  pressure,  innutrition,  and  general 
causes,  it  undergoes  fatty  metamorphosis  and  is  finally  eliminated  by  the 
various  emunctories.  The  only  exce^Dtions  to  the  rule  that  the  lesions  of 
syphilis  are  due  to  a  localized  cell-accumulation  are  those  phenomena  already 
alluded  to  as  the  result  of  toxins  and  neuropathic  disturbance,  such  as  the 
general  symptoms  of  syphilitic  invasion,  roseola  and  alopecia,  and  certain 
nerve-  and  bone-  lesions  that  Avill  be  discussed  later  on. 

DuEATiox  OF  IxFECTiON. — According  to  Baumler,  the  infection  of 
syphilis  lasts  from  eighteen  months  to  three  3'ears,  after  which  it  is  ex- 
hausted. Following  the  cessation  of  the  active  period  of  S3^philis,  the  blood 
and  the  secretions  of  open  lesions  cease  to  be  contagious,  and  it  may  also 
be  stated  that  in  by  far  the  greater  jiroportion  of  cases,  especially  if  they 
have  been  properly  treated,  no  further  manifestations  of  syphilis  are  ever 
experienced.  Eeasoning  from  these  facts,  it  is  quite  logical  to  infer  that 
the  so-called  tertiary  period  of  sj^Dhilis,  to  which  attention  will  hereafter 
be  directed,  is  not  a  "stage'^  of  the  disease  at  all,  but  simply  a  period  of  gen- 
erally-unnecessary sequels,  and,  indeed,  such  is  now  the  teaching  of  our  best 
authorities  upon  the  subject.  Hutchinson.  Lee,  Lome,  Baumler,  Besia- 
decki,  Otis,  and  many  others  incline  to  this  view.  The  author  believes, 
furthermore,  that  the  j^rojDortion  of  cases  of  tertiary  syphilis  or  sequels  may 
be  considerably  abridged  by  remembering  that  some  of  them  are  probably 
suffering  from  the  excessive  or  injudicious  action  of  mercury  rather  than 
from  sequels  of  s^qDhilis. 

Lessened  Vital  Resistancy  in  Sypliilis. — The  existence  of  severe  syph- 
ilis, while  it  may  not  be  intrinsically  dangerous  to  life,  must  necessarily 
lessen  vital  resistancy  and  enhance  the  danger  of  intercurrent  disease. 
Dujardin-Beaumetz  states  that  it  is  a  common  saying  in  the  Hopital  Cochin 
that  a  patient  with  typhoid  fever  engrafted  upon  early  active  syphilis  is  a 
doomed  man.  This  lessened  resistance  during  active  syphilis  should  be  espe- 
cially noted  by  examiners  for  life-insurance,  as  it  is  a  question  with  which 
the  examiner  is  often  confronted.    The  risk  is  always  increased  to  a  greater 


LESSENED    VITAL    EESISTAXCT    IX    SYPHILIS. 


395 


or  less  degree,  and,  irrespective  of  the  apparent  physical  health  of  the  ap- 
plicant, this  is  worthy  of  most  serious  consideration,  especially  where  it 
cannot  be  shown  that  the  patient  has  been  thoroughly  treated  for  the  re- 
quired time.  It  must  he  admitted,  however,  that  an  attack  of  syphilis  is 
often  conservative  in  its  effects.  The  rigorous  regimen,  abstinence  and 
hygienic  ]3recautions  necessary  in  a  thorough  course  of  antisyphilitic  treat- 
ment are  often  so  beneficial  that  the  subject  is  in  better  general  condition 
in  the  end  than  he  was  before  he  contracted  syphilis.  This  will  be  touched 
upon  again  in  connection  with  the  relation  of  S3'philis  to  life-insurance. 

Syphilis  in  its  Relations  to  General  Surgery. — The  relation  of  syphilis 
to  surgical  diseases  and  operations  is  a  very  practical  point  for  consideration, 
especially  as  regards  the  influence  of  the  constitutional  infection  upon  the 


healing  of  wounds  and  the  repair  of  fractures.  To  avoid  a  lengthy  discus- 
sion of  the  subject  the  author  will  present  the  conclusions  drawn  from  his 
clinical  experience,  embracing  a  fairly  extensive  field  of  general  operative 
work  extending  over  a  period  of  twenty  years. 

1.  Early  mild  syphilis  in  patients  in  good  general  health  does  not  im- 
pair the  healing  of  wounds,  jDrovided  they  be  aseptic  and  free  from  sources 
of  irritation. 

2.  Early  severe  syphilis  does  not  interfere  with  wound-healing  when 
the  patient  is  under  proper  treatment  and  the  wound  surgically  perfect. 

3.  "What  has  been  said  of  wounds  in  the  foregoing  conclusions  also 
applies  to  fractures. 

4.  Injuries   and   surgical   diseases   involving   prolonged   irritation   are 


396  GENEKAL    INFECTION    OF    SYPHILIS. 

usually  retarded  in  healing  by  constitutional  syphilis.  Thus,  open  wounds, 
ulcers,  inflammations,  and  compound  fractures — especially  if  septic — are 
likely  to  do  badly.  Proper  treatment  for  the  syphilitic  infection  is  a  sine 
qua  non  for  repair. 

5.  All  surgical  injuries  do  badly,  on  the  average,  in  the  syphilitically- 
cachectic  and  mercurially-debilitated,  especially  in  sequelar  syphilis. 

6.  Summing  up,  it  is  to  be  understood  that  syphilis  retards  the  re- 
covery of  surgical  diseases  and  the  repair  of  wounds  in  direct  proportion 
as  the  patient  is  suffering  from  nutritional  perversions  and  defects  inci- 
dental (a)  to  the  duration  of  syphilitic  blood-taint,  (6)  to  the  cachexia 
23roduced  by  syphilis,  (c)  to  the  debility  produced  by  excessive  or  incorrect 
treatment,  and  (d)  from  a  greater  or  less  degree  of  irritation  of  the  injured 
part,  which  is  ojDerative  in  developing  the  local  syphilitic  influence  in  direct 
proportion  to  the  duration  of  the  irritation. 

Peognosis  of  Syphilis. — The  prognosis  of  syphilis  as  regards  cura- 
bility has  already  been  touched  upon.  The  prognosis  of  the  disease  as 
regards  the  life  of  the  patient  is  a  matter  difficult  to  determine,  as  is  obvious 
when  the  obscurity  and  wide  variation  in  type  of  the  more  remote  conditions 
produced  by  syphilis  are  taken  into  consideration.  Fatal  results  from  syph- 
ilis are  usually  incidental  to  sequelar  lesions  of  the  arterial  or  cerebro-spinal 
systems  or  the  viscera.  They  occur,  as  a  rule,  at  a  period  so  remote  from 
the  original  infection,  and  the  symptoms  are  so  obscure  as  regards  the 
specificity  of  their  origin,  that  it  is  practically  impossible  to  determine  the 
primary  cause  of  the  condition  in  a  very  large  proportion  of  cases.  This 
much  may  be  said,  however,  namely:  syphilis  is  a  disease  that  is  essentially 
benign  so  far  as  danger  to  life  is  concerned.  It  is  probable  that  in  well- 
treated  cases  the  average  longevity  is  not  seriously  diminished  by  the  dis- 
ease. In  cases  in  which  treatment  has  been  insufficient,  injudicious,  or 
altogether  neglected,  longevity  is  unquestionably  diminished,  to  what  ex- 
tent it  is  impossible  to  say,  as  there  are  no  data  to  be  obtained.  Consider- 
ing the  apparent  seriousness  of  the  manifestations  of  syphilis,  it  is  rather 
remarkable  that  fatalities  immediately  attributable  to  the  disease  so  infre- 
c[uently  occur.  A  point  that  has  been  fairly  well  established  is  that  patients 
who  have  had  syphilis  are  more  likely  to  develop  general  paresis  under 
nervous  and  mental  strain  than  non-syphilitics.  It  does  not  often  occur; 
but  when  it  does,  it  is  usually  before  middle  age. 

It  is  a  notable  fact  that  fatalities  from  syphilis  are  almost  entirely 
limited  to  the  period  of  sequels.  Cases  of  death  from  the  lesions  of  the 
active  period  are  very  rare.  In  twenty  years'  experience  the  author  does 
not  recall  a  single  case  of  the  kind. 

Prognosis  from  the  Life-insurance  Stand-point. — The  author  has  very 
frequently  been  asked  for  an  opinion  upon  the  relation  of  syphilis  to 
life-insurance.  A  few  words  upon  this  subject  may  be  serviceable  to  those 
engaged  in  life-insurance  examinations.     In  a  general  way,  the  author  be- 


PKOGXOSIS    OF    SYPHILIS.  397 

lieves  that  insurance  companies  entertain  a  mistaken  idea  of  the  manner 
in  which  syphilis  modifies  the  risk  of  insurance.  In  most  companies  the 
risk  is  accepted  after  a  certain  number  of  years  following  the  primary 
infection,  this  period  being  in  most  instances  ten  years  or  less.  In  the 
author's  opinion  the  years  immediately  following  the  period  of  active  in- 
fection in  the  class  of  persons  most  often  ap^olying  for  life-insurance,  espe- 
cially for  large  amounts,  are  the  safest  from  the  "risk"  stand-point.  The 
average  individual  in  comfortable  circumstances,  and  especially  those  of 
such  a  conservative  turn  of  mind  as  are  most  of  the  applicants  for  life- 
insurance,  submits  himself  to  thorough  and  prolonged  treatment  for  syph- 
ilis when  he  is  so  unfortunate  as  to  acquire  that  disease.  He  is  quite  likely 
to  follow  his  physician's  directions,  and,  in  so  doing,  reforms  and  regulates 
his  habits  of  life  in  such  a  manner  that,  as  already  remarked,  he  is  often 
healthier,  from  a  general  stand-point,  at  the  end  of  his  treatment  than  he 
was  prior  to  infectio^.  He  is  likely  to  take  excellent  care  of  his  health  for 
many  years  after  his  disease  is  apparently  cured,  appreciating,  as  he  does, 
the  necessity  of  care  and  watchfulness  in  guarding  against  the  return  of  a 
disease  a  cure  of  which  cannot  possibly  be  guaranteed  him.  Individuals 
who  die  as  a  result  of  syphilis — i.e.,  of  sequelar  lesions — are  usually  beyond 
middle  life,  most  frequentl}^  past  the  age  at  which  insurance  i&  likely  to  be 
applied  for.  At  this  time  the  individual  is  quite  likely  suffering  from  a 
combination  of  the  remote  nutritional  effects  of  syphilis  and  senile  degener- 
ation. Under  such  circumstances,  the  applicant  for  insurance  is  a  hazardous 
risk  in  direct  ^^roportion  to  his  age,  the  risk  being  disproportionately  great  as 
compared  with  healthy  individuals  of  the  same  age.  The  author  would 
advise  extreme  care  in  insuring  risks  beyond  middle  life,  and  would  suggest 
that  the  danger  is  compounded  very  rapidly  after  that  period.  As  for  per- 
sons of  early  adult  age  who  have  suffered  from  syphilis  and  have  been  well 
treated,  the  author  firmly  believes  that,  other  things  being  equal,  a  hundred 
such  individuals  may  be  insured  at  least  as  safely  as  a  hundred  who  have 
not  contracted  the  disease.  The  percentage  of  deaths  at  the  end  of  twenty 
years  is  not  likely  to  be  greater  in  syphilitics  than  in  non-syphilitics.  The 
exceptional  cases  of  death  attributable  to  syphilis  have  been  a  great  bugbear 
with  insurance  companies.  As  compared  with  persons  who  have  had  syph- 
ilis without  serious  results,  however,  they  amount  to  but  little.  It  would 
be  interesting  to  know  how  many  accepted  risks  have  lied  to  the  examiner. 
The  insurance  company,  strange  to  say,  is  often  in  the  position  of  discrimi- 
nating against  honesty.  Another  point  that  the  companies  might  consider 
with  advantage  is  the  fact  that  a  history  of  a  mild  attack  of  syphilis  is 
not  necessarily  a  criterion  of  the  safety  of  the  risk.  The  quality  and  dura- 
tion of  treatment  is  a  much  safer  standard  for  judgment.  Insuring  subjects 
with  active  syphilis,  or  within  two  or  three  years  after  infection,  is,  of 
course,  not  to  be  thought  of,  for,  as  already  noted,  syphilis  lessens  vital  re- 
sistancy  and  thus  enhances  the  danger  of  intercurrent  diseases  of  all  kinds. 


CHAPTEE  XVII. 
Early  Bbaix  and  Xerve  Syphilis. 

The  various  nervous  manifestations  of  early  syphilis  have  been  the 
subject  of  special  study  on  the  part  of  the  author,  and  have  been  considered 
important  enough  to  merit  se|3arate  and  detailed  consideration. 

Involvement  of  the  nervous  system  in  late  or  sequelar  syphilis  is  so 
common  that  all  practitioners  of  experience  have  met  with  syphilitic  nerve- 
phenomena  of  varying  types.  Nervous  phenomena  occurring  as  a  part  of 
the  clinical  picture  j^resented  by  the  secondary,  or  active,  period  of  the  dis- 
ease, while  not  rare,  are  often  overlooked  and  even  discredited  as  syphilitic 
possibilities  by  physicians  in  large  practice. 

On  the  other  hand,  surgeons  of  extensive  experience  in  the  treatment 
of  syphilis,  with  the  best  opportunities  for  the  study  and  systematic  man- 
agement of  the  disease,  have  come  to  regard  early  nerve  disease  in  syphilis 
as  so  frequent  as  to  be  of  special  pathologic  and  clinical  importance. 
Hutchinson  and  Fournier,  in  particular,  have  expatiated  u^Don  this  point, 
the  former  having  described  some  beautifully-typic  examples  of  nervous 
disease  occurring  within  the  first  year  or  two  of  syphilis.  In  one  of  his 
earlier  communications  Fournier  described  a  very  peculiar  form  of  anes- 
thesia or  analgesia  occurring  coincidently  with  the  roseola.  That  instru- 
ment of  diagnostic  jorecision,  the  ophthalmoscope,  has  demonstrated  beyond 
peradventure  of  doubt  the  occasional  occurrence  of  syphilitic  retinitis  within 
or  shortly  after  the  first  year  of  the  disease. 

Some  of  Hutchinson's  cases  are  by  no  means  indubitably  syphilitic; 
others,  however,  are  so  marked  as  to  be  beyond  controversy.  Apropos  of  the 
clinical  reports  of  this  admittedly-distinguished  authority,  the  majority  of 
conservative  diagnosticians  will  agree  that  he  takes  much  for  granted.  Some 
of  the  cases  of  nervous  syphilis  that  he  reports  are  substantiated  by  the 
authoritative  weight  of  an  eminent  opinion,  rather  than  by  clinical  data. 
Such  cases  aside,  however,  enough  clearly-cut  cases  remain  to  demonstrate 
the  accuracy  of  his  conclusions  upon  the  general  question  of  the  early  occur- 
rence of  nerve  syphilis. 

It  has  been  the  fortune  of  the  author  to  meet  with  a  number  of  cases 
of  varying  types  of  nervous  phenomena  occurring  in  the  early  months  of 
syphilis.  Some  of  the  manifestations  observed  are  quite  common  and  would 
deserve  no  attention  were  it  not  for  the  fact  that  their  neuropathic  origin 
is  not  generally  understood,  although  the  phenomena  presented  are  a  matter 
of  common  and  daily  observation.  These  simpler  and  more  common  phe- 
nomena have  already  been  alluded  to  as  part  of  the  so-called  syphilitic  fever, 
embracing    slight   neuralgias   in    different    situations,    varying    degrees    of 

(398) 


MICROBIAL    ORIGIN.  399 

cejDhalalgia,  extreme  mental  depression,  and  rheumatoid  pains  in  different 
parts  of  the  body — symptoms  that  may  occur  at  any  time  during  active 
syphilis  independently  of  syphilitic  fever. 

The  various  forms  of  nerve  and  brain  disease  of  syphilis  have  received 
attention  chiefly  as  phenomena  of  late  syphilis,  and  even  in  the  late  cases 
it  has  been  considered  sufficient  to  classify  them  as  nervous  lesions  without 
attempting  a  critic  study  of  the  varying  conditions  underlying  them.  The 
terms  diffuse  and  circumscribed  gummy  infiltration  have  covered  a  multi- 
tude of  pathologic  conditions  of  widely-varying  types.  There  is,  to  be  sure, 
more  uniformity  in  the  pathogenesis  of  late  nerve  disease  than  in  the  early 
forms;  yet,  in  a  general  way,  what  will  be  said  of  the  precocious  forms  will 
apply  in  a  certain  degree  to  the  more  systematic  later  types.  There  is  often 
in  the  later  forms  a  very  important  plus  factor  in  the  etiology  due  to  ex- 
cessive drugging  and  the  syphilitic  cachexia.  This  factor  may  exist  in 
early  cases,  but  is  exceptional.  The  prognosis  in  all  forms  of  nerve  syphilis 
is  fairly  good,  if  we  except  the  debatable  cases  of  tabes  and  general  paresis. 
With  early  and  thorough  treatment  the  prognosis  is  much  more  favorable 
than  is  usually  believed  even  in  the  sequelar  types. 

It  is  worthy  of  note  that  the  more  typic  the  lesion  in  late  syphilis, 
the  better  the  prognosis;  thus,  a  definite  gummatous  deposit  may  always 
be  expected  to  yield  to  judicious  treatment.  Unyielding  symptoms  are  due 
to  lesions  that  may  be  termed  post-syphilitic,  in  the  true  sense  of  the  term, 
or  to  nutritional  disturbances  produced,  not  by  the  action  of  syphilitic 
poison  in  loco,  but  by  the  pressure  and  irritation  of  products  that  have 
usually  long  since  lost  their  infectious  properties.  The  author  believes  that 
all  tertiary  changes  are  essentially  post-syphilitic,  and  cannot  regard  tabes 
and  paretic  dementia  in  any  other  light,  where  there  is  reason  to  accept 
them  as  syphilitic  in  origin. 

The  prognosis  as  regards  recurrence  is  excellent,  in  well-treated  late 
cases  of  gummous  nerve  disease.  This  is  apparently  not  so  true  of  the 
early  cases.  It  may  be  that  the  necessity  for  vigorous  treatment  is  not  so 
well  appreciated  in  the  earlier  periods;  but  be  that  as  it  may,  the  occur- 
rence of  neuropathic  disturbances  in  early  syphilis  is  likely  to  be  a  pre- 
monition of  future  and  more  serious  nerve  trouble. 

In  the  author's  opinion,  a  clear  understanding  of  the  principles  of 
pathogenesis  underlying  the  early  nerve  phenomena  of  syphilis  can  only 
be  obtained  by  regarding  the  disease  as  microbial.  Independently  of  the 
question  of  the  known  or  unknown  character  of  the  germ,  analogic  reason- 
ing alone  should  convince  the  intelligent  observer  of  the  logic  of  this  view. 

Having  accepted  this  premise,  another  point  is  to  be  considered,  viz.: 
the  modus  operandi  of  the  germ.  In  a  general  way  it  may  be  stated  that  the 
germ  of  syphilis  follows  a  very  regular  and  systematic  evolution  or  life- 
history.  As  with  all  pathogenic  microbes,  therefore,  we  must  take  into  con- 
sideration (1)  the  soil,  (2)  the  action  of  the  germ  per  se,  and  (3)  the  action 


400  EAKLY    BRAIX    AXD    XEEYE    SYPHILIS. 

of  certain  toxins  that  it  produces  (a)  by  its  own  excretory  functions;  (h) 
by  the  morbid  changes  that  it  excites  in  the  tissues  in  which  it  operates. 

The  action  of  the  germ  may  be  said  to  be,  in  brief,  the  excitation  of 
morbid  impulses  and  new  properties  in  certain  anatomic  tissue-elements — 
the  cell-elements.  These  new  properties  are,  as  noted  in  the  preceding 
chapter:  (1)  a  tendency  to  rapid  proliferation;  (2)  a  tendency  to  fatty  de- 
generation; (3)  infectiousness.  In  time,  as  the  life-history  of  the  germ  is 
completed,  the  property  of  infectiousness  disappears  from  the  morbid  tis- 
sues, but  the  other  evil  properties  remain  so  long  as  the  leasi  trace  of  the 
syphilitic  impress  exists.  The  effect  of  the  toxins  may  still  remain,  though 
no  new  ones  are  formed,  save  by  the  cell-changes  themselves, — metabolic 
toxins.  The  tissues  know  the  germ-toxins  no  longer,  save,  perhaps,  by  their 
effects.  The  action  of  the  early  toxins  may  lay  the  foundation  for  cell- 
changes  occurring  long  after  the  germ  has  fulfilled  its  mission  and  disap- 
peared. 

The  relation  of  such  debatable  diseases  as  tabes  and  paretic  dementia 
to  early  intoxication  of  the  brain  and  cord  is  yet  to  be  shown,  but  it  is  prob- 
able that  such  early  nerve-intoxication  may  have  much  to  do  with  these 
late  j)henomena.  What  Hutchinson  terms  "vulnerability"'  may  thus  be  ra- 
tionally explained. 

The  author  will  state,  in  passing,  that  most  physicians  seem  to  regard 
syphilis  in  the  light  of  a  tissue-destroyer,  the  syphilitic  poison  being  sup- 
posed to  roam  about  like  the  traditional  lion,  seeking  innocent  cells  and 
fibers  to  devour.  This  is  a  serious  error,  and  has  been  responsible  for 
much  wild  pathology  and  still  wilder  therapeutics.  Syphilis  is  a  builder  of 
tissue, — such  as  it  is, — and  destroys,  not  by  corrosion,  but  largely  by  press- 
ure-innutrition. Perhaps  some  of  the  severe  lupoid,  necrotic,  and  phage- 
denic lesions  of  tertiary  syphilis  may  be  quoted  in  contradiction,  but  it 
is  easy  to  show  their  fallacy.  As  a  matter  of  fact,  the  disease  is  only 
apparently  destructive,  and  even  its  apparent  destructiveness  is  generally 
manifested  after  the  germ  has  probably  disappeared.  With  reference  to 
prognosis,  there  is  this  to  be  said,  viz.:  if  the  syphilized  cells  constituting 
syphilitic  neoplasia — whether  situated  in  the  nervous  system  or  elsewhere — 
be  removed  before  pressure-innutrition  and  absorption  of  the  tissue- 
elements  have  occurred,  perfect  recovery  ensues.  The  more  delicate  the 
structure,  the  more  quickly  must  the  removal  be  accomplished.  The  practi- 
tioner must  beware  of  delay  in  those  obscure  cases  of  sudden  deafness, 
certain  cases  of  disseminate  or  patchy  choroiditis  and  neuro-retinitis  occur- 
ring in  syphilitics.  These  affections  when  neglected  in  the  slightest  de- 
gree— and  often  ab  initio  in  neuro-retinitis — rank  witli  tabes  and  general 
paresis  with  respect  to  their  curability. 

The  practitioner  should  remember  that  his  remedies  may  effectually 
cure  syphilis,  yet  fail  to  remove  the  ruins  produced  by  it.  If  we  examine 
a  scar  left  by  subcutaneous  resolution  and  absorption  of  a  syphilide  and 


EAELY    BKAIN   AND    NEEVE    SYPHILIS.  401 

then  imagine  a  similar  scarring  of  nerve-tissue  or  arterial  wall — if  the  ex- 
pression is  permissible — some  obscure  points  in  syphilitic  neuropathology 
and  therapeutics  are  at  once  made  clear.  Apropos  of  this  proposition,  the 
author's  position  regarding  the  administration  of  mercury  in  some  forms  of 
nerve  syphilis  may  be  readily  surmised.  The  failure  of  mercury  and  the 
iodids  in  tabes  and  paretic  dementia  has  often  been  used  as  the  chief  argu- 
ment of  those  who  deny  the  specific  origin  of  these  diseases.  As  well  say  that 
a  long-standing  case  of  paraplegia  cannot  possibly  be  of  specific  origin,  be- 
cause, forsooth,  mercury  and  iodin  fail  to  cure  it.  Another  point:  Mercury 
and  iodin  may  remove  the  adventitious  deposit  very  quickly,  yet  fail  to  im- 
press the  now  fully-organized  connective  tissue  that  has  been  thrown  out 
as  a  consequence  of  the  irritation  induced  by  the  syphilitic  neoplasm.  To 
the  neurologist  there  may  be  nothing  novel  in  this  view;  yet  how  few 
general  practitioners  understand  it. 

As  is  readily  apparent  from  what  has  already  been  said,  syphilitic  toxins 
occupy  a  very  prominent  position  in  the  etiology  of  early  syphilitic  nerve 
disease.  They  also  bear  a  more  remote  relation  to  some  of  the  later  types  of 
nerve-phenomena.  It  now  remains  to  consider  how  they  act.  Apparently 
in  several  ways,  viz.: — 

(A)  By    direct    intoxication    of    nerve-  !     ' 


tissue 


2.  Ganglionic. 
I  3.  Perij)heral. 


(B)  By    the    induction    of    vasomotor  f  1.  In  the  vessels  of  the  central 

changes  via  the  sympathetic  gan-  !  nerve-system, 

glia  or  the  so-called  monarchical  }  2.  In  peripheral  vessels, 

vasomotor  center  in  the  medulla  I  3.  In  visceral  vessels. 

(C)  Direct    intoxication    and    irritation  K^ 't-.      .  ,- 

„  1       ,  •  1     ■        .12.  rassive  congestions. 

of   vascular  tissue    producing   m  <  „    t   ^  , .  „      , 

,,  ,  3.  Innammations  ot  a  low  type, 

the  nervous  system  ,    tt  -,    ■ 

1^  4.  Hyperplasias. 

The  question  at  once  suggests  itself:  If  toxins  are  present  in  syphilis 
and  they  are  so  variously  and  multitudinously  pathogenic,  why  do  not  all 
syphilitics  present  such  results  in  greater  or  less  number  and  severity?  To 
the  philosophic  clinician  such  a  query  would  never  suggest  itself;  but  the 
practitioner  who  is  impressed  with  the  typically-specific  character  and 
routine  effects  of  S5''philis  on  the  average  might  well  be  expected  to  be  a 
doubting  Thomas.  The  plus  factors  in  syphilis  are  too  little  appreciated 
even  by  the  expert.  The  physician  who  sees  nothing  peculiar  in  the  de- 
termination of  a  mucous  ulcer  by  the  irritation  of  a  jagged  tooth  or  tobacco- 
juice,  is  at  once  at  sea  when  confronted  with  a  syphilitic  nervous  disorder. 
The  relation  of  cause  and  effect  is,  it  is  true,  not  so  easily  determined  in 


402  EAELT    BEAIX    AXD    XEEYE    SYPHILIS. 

the  latter,  hut  it  is  none  the  less  definite.  Throughont  the  course  of  syph- 
ilis we  find  lesions  that  are  determined  hy  very  simple  and  common  factors. 
Thns,  long-continned  mncons  irritation  determines  mucous  plaques,  ulcers, 
papillary  hypertrophies,  fissures,  tuhercles,  and  condylomata.  Gouty  and 
rheumatic  irritation  of  muscle,  tendons,  ligaments,  and  s3movial  memhranes 
determines  so-called  syphilitic  and  mercurial  rheumatism.  Gout  and  rheu- 
matism jn'edispose  to  iritis,  neuralgias,  and  infiltration  of  arteries.  Just  so 
surely  do  such  sources  of  irritation  as  alcoholism,  sexual  excess,  the  gouty 
and  rheumatic  diatheses,  mental  overexertion,  or  worry  determine  nervous 
disease  of  a  type  corresponding  to  the  seat  of  irritation.  This  applies  not 
only  to  the  toxin  neuroses,  but  to  phenomena  due  to  structural  changes: 
i.e.,  to  those  characterized  by  syphilitic  new  growth.  The  element  of  hered- 
ity is  of  importance,  but,  as  we  well  knoAv,  a  neuropathic  tendency  may  exist 
without  it. 

Acute  complicating  diseases  are  not  usually  credited  with  the  power  of 
aggravating  syphilis;  but  the  fact  none  the  less  remains  that  general  or 
local  impairment  of  nutrition  is  likely  to  determine  syphilitic  action.  The 
more  prolonged  and  irritating  the  process,  the  better  the  prospect  of  an 
outcropping  of  the  specific  taint. 

There  is  no  disease,  perhaps,  that  more  actively  predisposes  to  nervous 
disturbance  in  syphilis  than  grip.  The  author  could,  from  his  own  clinical 
experience,  formulate  quite  a  lengthy  dissertation  on  syphilo-grippal  neu- 
roses. In  general,  there  is  no  condition  more  troublesome  than  a  combi- 
nation of  grip  and  syphilis — grippo-  and  syphilo-  toxins. 

One  of  the  most  important  factors  in  nervous  vulnerability  in  syphilis 
is  defective  elimination.  Xot  onl}^  do  the  S3'philitic  toxins  give  rise  to 
serious  results  under  such  circumstances,  but  the  patient  shows  intolerance 
of  antisyphilitie  remedies.  The  so-called  idiosyncrasy  that  makes  mercury 
and  the  iodids  obnoxious  to  certain  patients  often  means  defective  elimina- 
tion. Iodic!  intolerance  may  signify  a  sluggish  or  damaged  kidney.  The 
influence  of  trauma  in  the  determination  of  syphilitic  processes  must  be  ad- 
mitted; this  applies  to  nervous  as  well  as  to  other  lesions.  A  clean  incised 
wound  in  a  syphilitic  will  heal  readily,  but  prolonged  irritation  develops  a 
syphilitic  element  that  interferes  with  repair. 

From  this  brief  survey  of  the  determining  factors  of  syphilitic  phe- 
nomena, it  is  evident  that  the  question  of  vulnerability  of  tissues  and  organs, 
and  especially  of  the  nervous  system,  is  of  great  practical  importance.  The 
author  has  admitted,  for  the  sake  of  argument,  that  all  syphilitics  do  not 
present  early  toxin  neuroses,  for  the  routine  neuroses  described  in  the  pre- 
ceding chapter  are  not  generally  accepted  as  such. 

To  sum  up  the  question  of  toxins  in  early  s3qDhilis,  the  author  is  of 
opinion  that  they  bear  a  most  important  relation  to  the  cephalalgias,  neu- 
ralgias, bone-pains,  myalgias,  paralyses,  and  rare  cases  of  mental  disturbance 
found  in  early  syphilis,  which  affections  for  the  most  part  are  an  evidence 


EAELY    BEAIN    AND    NEEVE    SYPHILIS.  403 

of  the  action  of  toxins  on  tlie  nervous  system — botli  central  and  periph- 
eral— and  especially  upon  the  sympathetic.  These  disturbances  are  often 
transitor}',  independently  of  treatment,  but  they  leave  behind  them  a  vul- 
nerability of  nerve-tissue  that  may  determine  much  more  serious  trouble 
later  on.  Precisely  how  the  toxins  act  we  do  not  know — we  are  as  ignorant 
here  as  in  the  case  of  many  other  organic  poisons.  That  vascular  changes 
bordering  on  inflammation  of  nerve-structure  and  its  envelopes  occur  in 
some  cases  is  probable  enough,  but  difficult  of  proof.  The  earlier  the  dis- 
turbance, the  less  likely  it  is  to  be  due  to  organic  cell-deposit. 

In  concluding  the  subject  of  the  relation  of  toxins  to  syphilitic  nerve 
and  brain  disease,  the  author  desires  to  call  attention  to  one  point  involved 
in  the  views  of  Bannister  to  which  he  must  take  exception.^  This  distin- 
guished authority  believes  in  the  syphilo-toxic  origin  of  some  cases  of  general 
paresis,  but  holds  that  the  toxin  remains  latent  in  the  system  for  a  prolonged 
period.  He  does  not  believe  that  the  toxins  prepare  the  way  for  paresis,  but 
that  they  exist  and  are  operative  at  the  time  the  paresis  begins.  With  the 
latter  point  the  author  cannot  agree.  It  is  more  probable  that  with  the 
cessation  of  bacterial  evolution  the  toxins  are  eliminated  and  not  stored  up 
for  future  morbid  action.  Bacterial  evolution  probably  ends  with  the  ces- 
sation of  the  active  period,  long  before  general  paresis  develops.  Cerebral 
syphilo-toxemia  may  pave  the  way  for  paresis,  but  it  probably  does  so  by 
profoundly  perverting  the  biochemism  and,  possibly  in  a  minor  degree,  the 
structure  of  the  cerebral  tissues.  This  impression  produces  no  very  disas- 
trous results  in  the  early  history  of  the  case,  but  later  on,  as  nutrition  be- 
comes relatively  impaired  by  advancing  age  and  directly  impaired  by  inter- 
vening pathogenic  factors,  serious  trouble  results.  It  is  a  fact  well  known 
in  pathology  that  early  damage  to  tissue  may  not  reveal  itself  for  many 
years — this  aside  from  disease  due  to  germ-infection.  This  is  even  true  of 
some  cases  of  malignant  disease  of  late  clinical  development. 

In  studying  the  nervous  phenomena  inferentially  due  to  cell-infiltra- 
tion in  early  syphilis,  it  is  to  be  understood  that  it  is  difficult  to  difEerentiate 
them  from  the  toxin  variety.  The  later  the  development  of  the  phenomena, 
the  greater  the  probability  of  the  existence  of  definite  organic  lesions.  In 
late  secondary  and  tertiary  lesions  these  may  be  well  marked.  In  a  general 
way,  the  toxin  neuroses  have  their  point  of  departure  during  the  first  three 
or  four  months  of  syphilis,  the  later  varieties  being  of  neoplastic  origin, 
but  perhaps  complicated  by  toxinsi  The  younger  and  more  active  the 
germ,  the  more  virulent  and  abundant  its  toxins.  In  the  true  sequelar 
period  the  syphilitic  germ  and  its  toxins  are  probably  no  longer  a  factor  in 
syphilitic  neuropathology,  save  as  respects  the  tissue-vulnerability  and  mor- 
bid cell-impulse  already  described. 

The  exceptions  to  the  general  rule  regarding  the  dependence  of  the 


H.  M.  Bannister:    Journal  of  Nervous  and  Mental  Diseases,  .Januaiy,  1894. 


404  EAELY    BBAIN    AXD    NEEVE    SYPHILIS. 

very  early  nerve  disturbances  upon  toxins  are  chiefly  cases  in  which  hemi- 
plegia or  some  severe  forms  of  paralysis  develop;  in  hemiplegia  especially 
the  inference  that  a  localized  cell-accumulation  exists  is  usuall}^  justifiable. 
Organic  or  functional  nervous  disturbance  is  produced  by  syphilitic  new 
growth  in  numerous  ways,  viz.: — 

1.  By  invading  the  lymphatics  surrounding  nervous  structures. 

2.  By  involving  the  tissues,  chiefly  the  lymphatic  vessels,  surrounding 
the  blood-vessels  supplying  or  draining  the  part. 

3.  By  invading  the  arterial  walls. 

4.  By  infiltration  of  connective  and  other  tissues  about  nervous  struct- 
ures. 

5.  By  involvement  of  the  nerve  or  brain  parenchyma  proper. 

6.  By  involving  nerve-sheaths  or  the  cerebro-spinal  meninges. 
These  various  conditions  act  by  producing:— 

1.  Irritation. 

2.  Pressure-innutrition,  and  occasionally  degenerations. 

3.  Passive  hyperemia  and  edema  from  venous  obstruction. 

4.  Localized  anemia  (ischemia)  from  arterial  obstruction. 

6.  Blocking  up  of  the  affected  area  by  lymphatic  obstruction. 

It  is  rare  that  extensive  destruction  of  tissue  from  breaking  down  of 
the  neoplasm  occurs  in  the  earlier  nervous  lesions.  It  is  to  be  remembered, 
however,  that  gumma  may  develop  at  an  early  period  from  the  intrinsic 
malignancy  of  the  disease. 

The  predilection  of  syphilitic  cell-growth  for  lymphatic  glands  and 
capillaries  has  already  been  expatiated  upon.  That  most  of  the  neoplasia 
of  syphilis  are  essentially  processes  of  lymphatic  infiltration  and  obstruction 
is  not  only  true  of  the  active,  but  also  of  the  sequelar,  or  gummy,  period. 
In  the  latter,  however,  the  process  is  largely  one  of  lymphatic  obstruction 
and  congestion,  while  in  the  former  essential  infiltration  of  lymphatic 
structures  exists.  The  difference  between  the  two  may  possibly  be  explained 
by  the  hypothesis  that  the  gummata  are  chiefly  due  to  old-time  injury  of 
lymphatic  tissue  by  essential  tymphatic  infiltrations  incidental  to  the  active 
period. 

Vascular  involvement — direct  or  by  the  pressure  of  syphilitic  cell- 
growth — is  probably  the  most  important  factor  in  the  etiology  of  organic 
nervous  disease  in  early  syphilis;  as  already  remarked,  however,  the  more 
remote  the  period  after  the  chancre,  the  more  likely  the  process  is  to  be  due 
to  arterial  disease. 

The  apparent  predilection  of  the  sj^philitic  process  for  arteries  of 
medium  size,  and  especially  those  of  the  brain,  is  well  recognized,  but  has 
not  been  satisfactorily  explained.  A  brief  reconsideration  of  a  special 
anatomic  point — that  still  further  emphasizes  the  importance  of  lymphatic 
pathology  in  syphilis — makes  this  circumstance  fairly  intelligible. 

The  perivascular  lymph-spaces  are  an  integral  eleinent  of  the  lymphatic 


EAELY    BEAIN    AND    NERVE    SYPHILIS.  405 

system,  and  share  in  its  special  susceptibility  to  syphilitic  involvement. 
Pressure  upon  and  inelasticity  of  small-  or  medium-  sized  arteries  quite 
seriously  disturbs  the  nutrition  of  the  supplied  area,  with  consequent  aberra- 
tion of  function  in  the  latter.  This  is  a  very  important  matter  as  regards 
the  brain.  The  perivascular  spaces  of  the  large  trunks  are  involved,  it  is 
true;  but  the  resultant  pressure  and  inelasticity  are  a  trivial  matter  in  com- 
parison with  the  resisting  power  of  the  large  arterial  tubes  and  the  relative 
quantity  of  fluid  forced  through  them. 

Another  vital  point  is  this:  the  tunica  adverititia  of  the  vessels  is 
probably  a  part  of  the  lymphatic  system;  it  certainly  is  extensively  involved 
in  early  syphilis.  Hutchinson  seems  to  believe  that  the  tunica  intima  is 
primarily  involved,  the  adventitia  sometimes,  and  the  middle  coat  only 
secondarily;  but,  despite  so  weighty  an  opinion,  the  author  inclines  to  the 
view  that  the  point  of  departure  is  the  adventitia.  Apparent  evidence  to 
the  contrary  probably  depends  upon  the  fact  that  most  of  the  cases  studied 
have  been  late  cases  in  which  serious  and  extensive  secondary  changes  have 
occurred  in  the  vascular  walls. 

Hutchinson  says  that  syphilitic  arteritis  does  not  produce  aneurism. 
This  is  true  as  regards  the  early  stages,  but  the  endarteritis  of  late  syphilis 
is  a  most  prolific  cause  of  those  miliary  aneurisms  that  bear  so  important  a 
relation  to  cerebral  disease,  especially  of  the  apoplectic  variety. 

With  reference  to  Mr.  Hutchinson's  opinions  of  vasculo-cerebral  syph- 
ilis, it  is  a  peculiar  fact  that  some  of  the  cases  that  he  records  are  directly 
opposed  to  his  own  views  regarding  the  point  of  departure  of  the  pathologic 
process.  He  quotes  a  case  reported  by  Sharkey,  in  the  transactions  of  the 
Pathologic  Society  of  London,  of  a  man  who  died  of  vasculo-cerebral  dis- 
ease in  the  seventh  month  of  syphilis  while  still  covered  with  a  secondary 
eruption.  The  disease  was  symmetric,  affecting  both  middle  cerebrals.  ''The 
process  had  begun  in  the  tunica  adventitia  cvnd  had  spread  inward.'''^  Both 
arteries  were  occluded,  the  right  completely  so,  and  the  areas  supplied  by 
them  were  softened.  The  patient  had  suffered  from  headache  and  was 
under  treatment  for  syphilis  when  he  suddenly  passed  into  a  semicomatose 
condition,  with  convulsions  of  the  extremities;  in  this  state  he  remained 
until  his  death,  one  week  later.  Another  case  quoted  is  from  Dr.  Clifford 
Allbutt,  of  Leeds.  The  age  of  the  patient's  syphilis  is  not  given.  In  the 
brain  were  found  scattered  masses  of  syphilitic  neoplasm  involving  the 
smaller  arteries;  these  varied  from  the  size  of  a  pea  to  a  walnut  and  were 
somewhat  indurated.  "Microscopic  examifiation  shoived  that  the  process 
began  ivith  cell-exudation  and  proliferation  in  the  perivascular  canals, 
finally  causing  great  perivascular  thickening.'''^ 

The  support  afforded  by  these  cases  to  the  view  the  author  has  ex- 


^  Italics  the  author's. 
^  Italics  the  author's. 


406  EARLY    BKAIX    AXD    XEEYE    SYPHILIS. 

pressed  regarding  the  relation  of  tlie  tunica  adrentitia  and  the  perivascular 
lymph-spaces  to  the  initial  arterial  lesions  of  syphilis  is  very  noticeable.  It 
would  appear  that  Hutchinson  has  formed  his  conclusions  mainly  from 
cases  of  late  syphilis  in  which  the  point  of  arterial  departure  is  often  lost 
in  the  extensive  gummy  changes  and  secondary  degenerations  of  this  period. 
The  earlier  vascular  changes  that  are  really  at  the  bottom  of  the  difficulty 
have  usually  disappeared,  the  later  changes  that  replace  them  being  given 
credit  for  the  entire  field  of  pathologic  change.  In  the  presence  of  large 
diffused  gummata,  with  or  without  degeneration  of  the  inner  tunic  of  the 
vessels,  it  is  by  no  means  surprising  that  the  earlier  changes  are  masked, 
imderestimated,  or  entirely  overlooked;  even  though  they  have  not  com- 
pletely disappeared,  they  might  be  expected  to  have  done  so.  Early  peri- 
vascular exudate,  especiallv,  may  produce  most  disastrous  effects  on  vascular 
wall-nutrition  and  yet  be  removed  in  due  time.  Its  presence  in  tertiary 
cerebral  syphilis  would  be  conclusive;    its  absence,  however,  argues  little. 

It  is  probable  that  the  arterial  changes  of  early  syphilis  are  chiefly 
operative  in  the  production  of  ischemia  of  the  brain-  and  nerve-  tissue,  with 
resultant  loss  of  function.  Vicarious  hyperemia  from  obstruction  of  certain 
areas,  and  compensatory  pressure  in  others  supplied  by  sound  vascular  twigs 
from  the  same  vessel,  are  possible  elements.  Passive  congestion  and  edema 
from  venous  involvement  are  additional  possible  factors.  Hutchinson  has 
called  attention  to  a  peculiar  form  of  periphlebitis  due  to  syphilis;  this  may 
occur  in  the  brain. 

It  is  not  beyond  the  bounds  of  logic  to  assert  that  all  of  the  conditions 
described  may  possibly  co-exist,  and  that  intoxication  by  syphilitic  toxins 
may  be  superadded. 

Hemorrhages,  distinct  tumors,  embolism,  thrombosis,  vascular  ulcera- 
tions— softening  of  the  tunica  intima — are  not  to  be  expected  in  this  early 
stage.  Intracranial  nodes,  while  possible,  are  certainly  rare  at  this  time. 
Meningeal  infiltrations  probably  occur,  but,  as  a  rule,  do  not  seem  to 
excite  symptoms.  Such  damage  as  may  be  done  early  in  the  disease  mani- 
fests itself  by  symptoms  at  a  relatively  much  later  period. 

It  is  obvious,  from  what  has  been  said,  that  the  changes  mentioned  as 
characteristic  of  syphilitic  cell-deposit  are  much  more  likely  to  be  localized 
than  those  due  to  a  universally-circulating  toxin.  It  is  to  be  remembered, 
however,  that  the  toxin  may  cause  symptoms  referable  to  a  particular  area 
of  nervous  distribution,  by  producing  aberrations  of  vasomotor  impulse 
through  its  action  on  the  sympathetic. 

Involvement  of  nerve-  and  brain-  tissue  proper  by  neoplastic  deposit 
has  been  mentioned  as  occurring  in  very  early  syphilis,  but  it  must  be 
very  rare.  Such  invasion  as  does  occur  must  be  slight,  and  acts  merely  by 
laying  the  foundation  for  later  gimimy  disease.  It  will  be  understood  in 
this  connection  that  the  possibility  of  precocious  gnmmata  of  the  brain  is 
not  denied.     In  such  cases,  however,  there  are  abundant  extracranial  evi- 


EAELY    BKAIN    AND    NEEYE    SYPHILIS.  407 

dences  of  malignancy.  In  a  general  way  it  will  be  found  that  large  circum- 
scribed gumniata  are  characteristic  of  the  period  of  sequels,  while  those  of 
the  earlier  jDeriod  are  not  only  small,  but  disseminate.  The  disseminated 
lesions  of  early  involvement  of  the  choroid  fairly  illustrate  what  may  be 
expected  in  the  brain  in  early  syphilis. 

The  cases  of  early  nerve-syphilis  that  have  been  reported  by  different 
authors,  among  whom  Hutchinson,  Kiernan,  Bannister,  Moyer,  and  ISTor- 
bury  occupy  prominent  positions,  can  hardly  be  classified  arbitrarily.  Those 
observed  by  the  author  may  be  fairly  divided  into:  (1)  cases  in  which  toxin 
poisoning  was  the  chief  factor;  (2)  cases  in  which  organic  cell-deposit 
existed  and  was  the  main  element;  (3)  mixed  cases  in  which  both  factors 
were  probably  well  marked.  That  these  conditions  are  often  absolutely 
independent  of  each  other  during  the  active  period  is  hardly  credible.  The 
author  will  again  direct  attention  to  the  fact'  that  the  probability  of  the 
presence  of  organic  cell-deposit  is  in  direct  proportion  to  the  duration  of 
the  case.  Some  of  the  very  early  nerve-phenomena  are  distinctly  toxemic; 
a  little  later  there  is  a  mixture  of  both  elements,  although  either  may  greatly 
jjredominate;  later  still,  the  toxin  factor  is  of  secondary  importance.  Xerve- 
phenomena  associated  with  a  simple  typic  roseola  may  be  accepted  as  prob- 
ably toxic.  The  existence  of  eruptions  consisting  of  cell-deposit  enhances 
the  probability  of  cell-infiltration  of  nervous  tissue  or  the  vessels  supply- 
ing it.^ 

Several  of  the  author's  cases  have  been  fair  examples  of  the  effects 
of  syphilitic  toxins  upon  the  brain.  Not  only  were  the  meninges  directly 
intoxicated  by  the  products  of  syphilitic  germ-evolution,  but  there  was,  in 
all  probability,  a  vasomotor  neurosis  that  constituted  a  still  more  powerful 
source  of  cerebro-meningeal  hyperemia.  The  line  between  such  conditions 
and  actual  inflammation  is  difficult  to  draw,  but.  Judging  by  the  effects  of 
known  syphilitic  ]3achymeningitis  later  on,  it  is  questionable  whether  actual 
inflammation  is  present  in  these  early  types  of  head  disturbance.  Its  occur- 
rence would,  however,  not  be  surprising,  Judging  by  the  effects  of  other 
poisons — that  of  rheumatism,  for  example — upon  the  meninges  and  brain. 
Pericranial  involvement  ma}^  in  the  author's  opinion,  be  laid  aside  in  these 
cases. 

When  we  consider  the  excessive  engorgement  of  the  pharynx  in  sec- 
ondary syphilis  we  ought  not  to  be  surprised  at  the  occasional  occurrence 
of  severe  symptoms  referable  to  meningeal  engorgement.  The  faucial 
hyperemia  has  been,  it  is  true,  referred  to  actual  cell-deposits;  but,  as 
stated  in  the  preceding  chapter,  the  author  believes  that  vasomotor  dis- 
turbance has  much  to  do  with  it. 


^  The  author's  paper  on  this  subject,  read  before  the  Chicago  Academy  of  Medi- 
cine, appeared  in  full  in  the  Journal  of  the  American  Medical  Association  in  March, 
1895.    It  contains  the  report  of  twelve  personal  and  a  number  of  quoted  cases. 


408  EAELY    BEAIX   AND   NERVE    SYPHILIS. 

It  Avould  appear  that  mental  disquiet  was  important  in  the  determina- 
tion of  head-symptoms  in  the  author's  cases.  This  is  an  important  practical 
point  as  tending  to  show  that  syphilis  alone  may  be  a  quite  different  matter 
from  syphilis  plus  anxiety,  brain-fag,  or  any  condition  that  tends  to  disturb 
cerebral  circulation  and  nutrition. 

One  case' of  severe  cephalalgia  in  a  chlorotic  female  syphilitic  clearly 
illustrated  what  may  occur  when  diathetic  conditions  and  blood-impoverish- 
ment are  superadded  to  syphilitic  infection.  It  has  seemed  to  the  author 
that  rheumatism,  gout,  tobacco,  and  alcohol  are  somewhat  alike  in  increas- 
ing vulnerability  of  nerve-  and  brain-  tissue  with  respect  to  both  syphilitic 
intoxication  and  cell-growth.  i\_lcohol  is  especially  open  to  impeachment  by 
virtue  of  its  pernicious  effect,  not  only  upon  the  brain-cells,  but  also  upon 
the  cerebral  circulation. 

ISTumerous  cases  of  spinal  neuralgia — intercostal,  lumbo-abdominal, 
and  general — occurring  in  early  syphilis  have  demonstrated  the  selective 
action  of  syphilitic  toxins  upon  the  posterior  spinal  nerve-roots.  One  of 
the  author's  cases,  a  young  man  in  his  early  twenties,  suddenly  developed 
hemiplegia  and  aphasia  in  the  early  eruptive  stage  of  syphilis.  Such  cases 
sometimes  arise  very  suddenly,  after  drinking,  sexual  excitement,  or  other 
source  of  cerebral  excitation,  demonstrating  very  conclusively  that  syph- 
ilitic brain  disease  may  remain  latent  for  some  time,  only  to  develop  upon 
the  supervention  of  some  exciting  cause.  Whether  this  is  true  only  of  the 
early  disturbances  of  syphilis  is  open  to  question.  It  is  a  fact,  however,  that 
in  early  cerebral  disturbance — due  either  to  toxins  or  gradual  diminution 
of  vascular  caliber,  or  both — the  onset  is  apt  to  be  insidious,  with  premoni- 
tory symptoms  of  vertigo,  slight  aphasia,  impairment  of  memory,  cephal- 
algia, sense  of  head-fullness,  melancholy,  irritability,  or  perhaps  muscular 
spasm.  The  final  stroke  may  be  sudden;  but  some  of  the  foregoing  symp- 
toms are  likely  to  have  preceded  it.  The  exceptionally-sudden  development 
of  several  of  the  author's  early  brain  cases  is  a  feature  of  great  interest. 
Later  cases,  that  may  be  due  to  thrombosis,  embolism,  or  hemorrhage,  are, 
of  course,  very  sudden. 

Bannister  relates  a  very  interesting  case  with  features  somewhat  simi- 
lar to  several  of  the  author's: — 

Case. — I  was  called  into  a  large  store  to  see  a  man  who  had  been  seized  with  an 
apoplectic  attack.  I  found  a  gentleman,  between  30  and  40  years  of  age,  completely 
hemiplegic  on  the  left  side.  He  had  not  lost  consciousness,  and,  while  mentally  some- 
what disturbed,  was  capable  of  giving  a  clear  account  of  himself,  which  was  verified 
by  his  friends.  He  had  been  well,  prior  to  the  attack,  with  the  exception  of  a  chancre 
contracted  four  months  previously.  I  had  him  taken  in  a  carriage  to  his  boarding- 
place  as  he  requested,  prescribed,  and  promised  to  call  the  next  day.  The  next 
morning  to  my  surprise  I  found  him  up  and  dressed;  all  motor  paralysis  had  dis- 
appeared, but  he  was  completely  aphasic  and  could  only  partially  express  himself 
by  signs.  I  learned  that  his  hemiplegia  had  left  him  during  the  night,  to  be  followed 
by  his  present  condition.     This  also  passed  off  within  twenty-four  hours;    but  his 


EAELY    BEAIX    AXD    XEEVE    SYPHILIS.  409 

mind  Avas  left  markedly  affected:    a  condition  of  mild  depression  and  partial  hebetude 
remained  which  continued  until  he  left  the  city  and  passed  out  of  my  knowledge. 

Bannister  considers  this  case  to  have  been  one  of  incipient  paretic  de- 
mentia due  to  toxic  cerebral  disturbance,  and  in  this  opinion  the  author  is 
inclined  to  agree,  but  with  some  qualifications.^  It  is  quite  unfortunate 
that  the  age  of  the  patient,  his  previous  habits  of  life,  heredity,  and  sub- 
sequent history  were  not  definitely  known.  These  points  would  possibly 
afford  additional  support  to  Bannister's  theory  of  the  case,  by  removing 
certain  features  of  doubt.  As  to  the  cerebral  intoxication,  it  was  doubtless 
a  very  important  factor  in  the  case;  but  there  were  certain  other  elements 
requiring  due  consideration.  In  the  first  place,  cell-deposit  was  to  have 
been  expected  at  the  time  the  hemiplegia  developed;  vasculo-cerebral 
changes  were  probably  present,  with  resulting  relative  ischemia  and  de- 
fective nutrition  of  the  brain.  The  toxins  undoubtedly  did  their  full  share 
in  perverting  nutrition  and  inhibiting  cerebral  function;  but  the  sudden 
paralysis  was  probably  explicable  by  their  vasomotor  rather  than  by  their 
direct  effect.  The  speedy  recovery  of  the  hemiplegia,  and  the  apparent 
alteration  of  the  morbid  process  from  right  to  left,  as  suggested  by  the 
aphasia,  which  replaced  the  left  hemiplegia,  tend  to  show  this.  Temporary 
vaso-contraction  of  arteries  the  lumen  of  which  was  already  diminished  by 
syphilitic  infiltration  would  serve  as  a  logical  explanation.  The  resulting 
mild  dementia  was  probably  due  to  the  combined  effects  of  the  temporary 
ischemia  and  the  syphilitic  toxins. 

Typic  examples  of  early  syphilitic  hemiplegia  afford,  when  well  treated, 
ample  evidence  of  the  favorable  character  of  the  prognosis.  A  very  im- 
portant point  in  this  connection  is  the  fact  that  such  cases  should  rarely 
occur.  We  cannot  avoid  in  some  cases — possibly  in  the  majority — the  early 
toxin-phenomena,  for  the  reason  that  treatment  may  not  have  time  tS 
thoroughly  impress  the  patient  before  the  symptoms  of  toxin  nerve  disease 
develop.  When,  however,  we  have  several  months'  leeway,  we  should  always 
be  able  to  prevent  early  symptoms  due  inferentially  to  arterial  disease,  pro- 
viding the  patient  be  intelligent  and  conscientious.  Eecovery  does  not 
ensue,  even  in  early  syphilitic  brain  disease,  unless  the  toxins  and  syphilitic 
neoplasm  be  removed  before  permanent  changes  in  the  affected  tissues  have 
occurred.  The  syphilitic  factor  in  such  cases  may  be  swept  away  easily 
enough,  but  we  must  be  very  prompt  and  radical  in  our  therapeutics,  else 
nerve-ruin  will  be  left  behind.    It  must  be -remembered  that  the  pathologic 


^  (a)  "Statistic  Note  on  Two  Hundred  and  Thirty-four  Cases  of  Paretic  De- 
mentia, with  Especial  Reference  to  Etiology."  H.  M.  Bannister,  Journal  of  Nervous 
and  Mental  Diseases^  1891. 

(ft)  Thesis  before  the  Chicago  Academy  of  Medicine,  by  H.  M.  Bannister,  en- 
titled "Paretic  Dementia :  A  Toxic  Disease."  .Journal  of  Nervous  and  Mental  Diseases, 
January,  1894.  


410  EAKLY    BEAIX    AND    KEETE    SYPHILIS. 

process  in  some  cases  may  be  precocious,  verging  upon  gumni)^  change; 
herein  lies  a  source  of  danger. 

In  a  case  of  early  hemianesthesia  of  the  author's  the  character  of  the 
lesion  is  an  open  question.  Cerebral  hemorrhage  should  be  rare  in  such 
early  cases,  the  thickening  of  the  vessel-walls  and  perivascular  tissue  pro- 
tecting the  arteries  from  rupture  rather  than  otherwise.  Collateral  vascular 
strain  and  hyperemia  induced  by  venery  and  alcohol  might  have  been  the 
essential  factor.  It  will  be  understood  that  the  probability  of  a  small  ex- 
travasation in  such  cases  is  not  denied.  The  author  simply  desires  to  assert 
its  rarity  at  so  earl_y  a  period  of  syphilis.  Its  occurrence,  however,  might 
show  that  the  localization  of  vasculo-cerebral  syphilis  depended  upon  some 
antecedent  non-syphilitic  disease.  This  is  not  likely  in  a  relatively-young 
subject.  The  occurrence  of  acute  ischemia  of  the  affected  area  is  not  im- 
probable. The  affected  area  probably  accommodates  itself,  as  a  rule,  to  the 
gradual  diminution  of  the  blood-supply  incidental  to  the  encroachment  of 
the  syphilomatous  process.  When,  however,  from  any  cause  the  vessels  are 
suddenly  occluded  the  result  is  well  known.  The  mechanism  of  this  occlu- 
sion in  early  syphilis  is  not  so  easily  explained.  Embolism  is  possible,  but 
is  not  to  be  expected  in  early  syphilis.  Localized  vasomotor  disturbance  is 
also  possible.  The  toxin  element  does  not  enter  here,  save  as  a  complicating 
factor;  that  it  is  the  essential  feature  of  the  case  is  not  likely.  After  a  care- 
ful survey  of  the  pathologic  possibilities  in  the  case  under  consideration  the 
author  inclines  to  the  ischemic  view  of  the  cerebral  disturbance.  The  loca- 
tion of  the  lesion  in  the  internal  capsule  or  its  immediate  vicinity  may  be 
taken  for  granted. 

The  subsequent  recovery  and  prolonged  good  health  of  this  patient 
typify  the  favorable  ultimate  prognosis  of  many  cases  of  nervous  syphilis. 
^  Among  the  author's  most  interesting  cases — a  man  of  middle  age — ^was 
one  of  combined  grip  and  the  first  efflorescence  of  syphilis.  Severe  spinal 
neuralgia  with  symptoms  suggestive  of  involvement  of  the  spinal  meninges 
developed  and  proved  most  trying  and  obstinate.  Some  months  later  this 
man  developed  severe  paraplegia.  A  prominent  factor  in  this  case  was 
excessive  sexual  indulgence  even  after  the  syphilitic  eruption  appeared. 
The  case  quite  forcibly  illustrates  three  important  features  of  syphilitic 
neuropatholog}^,  viz.: — 

1.  The  acutely  pernicious  action  of  syphilitic  toxins  upon  the  nervous 
system. 

2.  The  vulnerability  of  nerve-tissue  produced  by  this  early  intoxication. 

3.  The  importance  of  such  conditions  as  grip  and  possibly  the  influ- 
ence of  sexual  excess  in  determining  neuropathic  phenomena.  The  early 
nerve  disturbance  in  this  case  the  author  believes  to  have  been  due  to  the 
following  factors:  (a)  direct  irritation  of  nerve-tissue  and  spinal  meninges 
by  the  syphilitic  toxins;  (b)  circulatory  disturbance — probably  hyperemia — 
of  the  same  tissues  and  especially  of  the  posterior  roots  of  the  spinal  nerves. 


EAELT    BEAIN"    AND   NEEVE    SYPHILIS.  411 

produced  by  syphilitic  intoxication  of  the  sympathetic.  The  paraplegia  that 
occurred  later  on  was,  in  all  probability,  due  to  actual  cell-infiltration  of  the 
motor  tracts  determined  by  the  perversion  of  nutrition  left  by  the  toxins. 
For  that  matter,  the  paraplegia  did  not  occur  late  enough  to  exclude  toxin 
action  at  the  time  it  developed.  Even  if  the  toxins  were  the  point  of 
departure,  however,  cell-infiltration  was  probably  the  essential  factor  at  this 
time.  Grip  was  a  very  important  factor  in  the  early  symptoms.  This  dis- 
ease is  itself  a  powerful  toxin-elaborator.  Sexual  excess,  perhaps,  had  much 
to  do  with  the  spinal  determination  of  the  syphilitic  poison.  The  author 
is  inclined  to  the  view  that  the  causative  influence  of  syphilis  in  tabes  is 
often  operative  chiefly  through  the  secondary  factor  of  sexual  excess. 
Hutchinson  reports  a  case  in  which  acute  myelitis  was  precipitated  by  sexual 
indulgence,  the  patient  being  well  along  in  late  syphilis.  It  is,  of  course, 
recognized  that  the  relative  importance  of  syphilis  in  the  etiology  of  tabes  has 
not  been  definitely  settled.  Alcohol  bears  a  somewhat  similar  relation  to 
tabetic  etiology:  it  is  probably  the  determining  factor  that  develops  morbid 
changes  in  the  spinal  cord  in  syphilitics,  from  which  abstainers  would  prob- 
ably escajDO. 

The  author's  cases  comprise  several  involving  the  nerves  of  the  head 
and  face.  One  case,  in  which  the  fifth  nerve  was  affected,  is  an  illustration 
of  a  form  of  syphilitic  nerve  disease  which,  while  it  can  hardly  be  said  to 
be  very  rare,  is  yet  sufficiently  infrequent  to  be  of  great  interest.  It  would 
appear  that  syphilis  has  something  of  a  monopoly  in  the  production  of 
paralysis  of  the  fifth.  Hutchinson  states  that  he  has  never  seen  this  form 
of  paralysis  except  from  syphilis.  The  author  is  not  in  a  position  either  to 
verify  or  contradict  this  assertion.  JSTeurologists  of  large  experience  are 
much  more  competent  to  judge.  It  is  to  be  remembered,  however,  that  Mr. 
Hutchinson's  clinical  experience  has  been  enormous. 

The  only  cases  of  trifacial  paralysis  that  the  author  has  seen — two  in 
number — were  due  to  syphilis;  but,  strange  to  say,  neither  of  them  bore 
out  Mr.  Hutchinson's  favorable  prognostic  opinion  of  such  cases.  He  says: 
"I  do  not  recollect  a  single  case  of  syphilitic  paralysis  of  the  fifth  nerve 
which  was  permanent."  The  apparent  contradiction  in  the  author's  cases 
was  probably  due  to  the  late  period  at  which  proper  treatment  was  begun. 
In  neither  of  the  cases  Avas  the  cornea  involved,  the  superior  division  of 
the  nerve  probably  escaping  involvement.  Hutchinson  has  several  times 
removed  the  eyeball  in  cases  of  total  involvement  of  the  nerve,  the  anes- 
thesia from  the  nerve-lesion  being  so  complete  that  anesthetics  were  un- 
necessary in  operating.  As  a  rule,  only  one  nerve  is  involved,  cases  in 
which  bilateral  paralysis  of  the  fifth  or  coincidental  involvement  of  other 
cranial  nerves  being  exceptional.  Hutchinson  believes  that  the  want  of 
symmetry  and  strict  localization  of  the  lesion  shows  that  the  trunk  or 
ganglion  rather  than  the  origin  of  the  nerve  is  affected. 

A  most  interestino;  feature  of  one  of  the  author's  cases  was  unilateral 


412  EAKLY    BEAIX   AND   XEEVE    SYPHILIS. 

deafness.  So  rare  is  this  condition  that  Hntcliinson  states  that  he  has  never 
seen  an  example  of  it.  Partial  deafness  in  one  or  hoth  ears,  generally  tem- 
porary, is  by  no  means  unusual  in  early  syphilis.  Tinnitus  aurium  is  an- 
other aural  phenomenon  that  is  not  infrequent  and  is  likely  to  be  very 
stubborn,  but  may  not  be  accompanied  by  the  slightest  inhibition  of  audi- 
tion. In  the  eases  in  which  absolute  deafness  occurs  the  process  is  not 
only  bilateral,  but  may  be  fulminant.  Unless  mercury  be  vigorously  used, 
incurable  deafness  is  very  likely  to  develop  in  an  incredibly  short  time.  We 
are  almost  in  the  dark  regarding  the  pathology  of  these  cases. 

Deafness  develops  during  the  first  year  of  syphilis,  as  a  rule;  is  rarely, 
if  ever,  sequelar;  and  seems  to  be  almost  identic  in  acquired  and  heredi- 
tary syphilis,  in  which  latter  condition  it  is  very  frequent.  The  severity  and 
rapidity  of  the  process  in  connection  with  the  total  abolition  of  hearing 
that  usually  results  warrants  its  classification  among  the  nerve-phenomena 
of  syphilis.  A  disturbance  of  the  relations  of  the  arteries  to  their  bony 
investments  by  virtue  of  loss  of  elasticity,  thickening,  and  narrowing  of  the 
vessel-walls  probably  explains  some  of  the  slighter  cases  of  deafness  and 
tinnitus.  Some  transitory  cases  are  doubtless  due  to  a  syphilotoxic  vasom- 
otor neurosis. 

Where  cell-infiltration  in  or  about  the  auditory  nerve  occurs,  the  press- 
ure and  counter-pressure  on  the  delicate  nerve-fibers  must  be  very  great,  be- 
cause of  the  unyielding  nature  of  its  osseous  investments.  The  syphilitic 
neoplasm  may,  as  usual,  be  quite  speedily  removed,  but  jDressure  and  toxic 
innutrition  have  done  their  work,  and  permanent  and  functionally-fatal 
injury  has  been  produced.  The  author  sees  no  other  logical  explanation 
of  these  cases.  There  is  certainly  no  explanation  that  could  more  power- 
fully emphasize  the  necessity  for  early  and  radical  treatment. 

A  final  point  of  interest  is  the  fact  that  facial  hemiatrophy,  which 
occurred  in  one  of  the  author's  cases,  is  exceptionally  preceded  by  neuralgia 
of  the  fifth.    In  the  case  under  consideration  it  was  very  severe. 

Facial  paralysis  from  syphilis  is  very  rare,  while  it  is  very  frequent 
from  other  causes.  The  possibility  of  coincidence  is  therefore  to  be  taken 
into  serious  consideration  in  suspected  cases.  Hutchinson,  with  his  vast 
experience,  recalls  only  two  or  three  examples  of  facial  paralysis  from  syph- 
ilis, and  in  these  cases  other  cranial  nerves  were  also  involved.  He  quotes 
Buzzard  and  Hughlings-Jackson  as  having  recorded  examples  of  it.  In  a 
case  of  the  author's  there  was  no  change  for  the  better  until  full  mercurial 
treatment  was  instituted:  a  point  in  favor  of  the  diagnosis  of  sj^philitic  dis- 
ease of  the  seventh  nerve  or  its  root. 

In  cases  of  early  cord  symptoms  where  tabes  develops  at  a  remote 
period,  it  would  be  difficult  to  prove  the  connection  of  the  early  tabetic 
symptoms  of  undoubted  specific  origin,  with  the  later  manifestations  of 
typic  tabes.  The  inference  of  a  causal  relation  of  the  early  symptoms  to 
the  later  incurable  cord  disease  is,  however,  apparently  fair.    At  this  junct- 


EAELT    BEAIN    AND    NEEVE    SYPHILIS.  413 

lire  it  might  be  well  to  again  suggest  that,  in  many  cases  of  tabes  with  a 
syphilitic  history,  early  cord  intoxication  without  symptoms  may  have  laid 
the  foundation  for  later  changes. 

H.  N.  Moyer  has  observed  a  case  which  is  very  pertinent  as  bearing 
upon  early  spinal-cord  involvement  in  syphilis.  His  report  of  the  case  is  as 
follows : — 

Case. — I  was  called  to  see  a  woman,  about  30  years  of  age,  who  was  said  to  be 
suffering  from  an  obscure  nervous  trouble.  The  disease  had  begun  some  weeks  before 
I  saw  her,  with  severe  pain  in  the  back  and  shooting  pains  in  the  legs.  These  symp- 
toms had  gradually  increased  until  within  a  few  days  of  the  time  when  she  came 
under  observation,  at  which  time  she  was  compelled  to  take  to  her  bed.  At  the  time 
I  saw  her  she  was  apparently  very  sick  and  suffering  excruciating  pains,  particularly 
in  the  legs,  and  a  dull,  heavy  aching  in  the  back.  She  was  very  restless  and  sleepless. 
The  pains  were  described  as  shooting  or  darting  up  and  down  the  limb:  the  feet 
were  especially  painful  and  there  was  a  feeling  as  though  hot  sand  were  applied  to 
the  soles.  On  examination,  there  was  no  special  atrophy,  though  there  was,  perhaps, 
some  loss  of  power  in  the  legs.  She  was  able  to  stand  with  the  eyes  open,  but  with 
them  closed  she  would  immediately  pitch  forward.  The  knee-reflexes  were  completely 
abolished.  There  was  impaired  tactile  and  temperature  sense  in  the  lower  extremities. 
At  this  examination  I  detected  a  diffuse  macular  and  papular  eruption  pretty  gener- 
ally distributed  over  the  entire  body  and  which  up  to  that  time  had  not  attracted 
the  attention  of  the  attending  physician.  The  eruption  also  was  present  upon  the 
palms  of  the  hands.  Suspecting  the  specific  nature  of  the  eruption  I  immediately 
questioned  the  husband,  who  admitted  that  about  ten  months  before  he  had  been 
infected,  but  after  six  months'  treatment  his  physician  had  advised  him  to  marry, 
and  he  had  done  so. 

To  my  mind,  there  was  no  question  that  the  specific  infection  was  directly 
responsible  for  the  acute  ataxia  in  which  I  found  the  patient.  An  examination  of 
the  genital  organs  did  not  reveal  any  primary  sore.  I  saw  the  patient  on  one  or 
two  occasions  after  this  visit,  and  I  learned  subsequently  from  her  physician  that 
imder  free  use  of  the  iodids,  with  mercurial  inunction,  the  pains  rapidly  disappeared 
and  the  patient  made  a  quick  recovery.  Within  three  or  four  weeks  she  was  going 
about  attending  to  her  ordinary  household  duties.  It  would  be  interesting  if  at  this 
time  I  could  see  and  examine  the  patient,  but  unfortunately  I  do  not  know  where 
she  is.    It  is  the  earliest  case  that  has  ever  come  under  my  observation. 

It  has  not  been  the  author's  fortune  to  observe  cases  of  early  brain 
syphilis  with  mental  symptoms  as  the  predominant  element.  A  number  of 
such  cases  are  on  record.  Most  of  these  cases  have  been  collected  by  Kier- 
nan,  in  a  brief  yet  comprehensive  survey  of  the  literature  of  the  subject  of 
early  syphilitic  psychoses.^ 

Wille,  several  years  ago,  made  an  exceedingly  valuable  analysis  of  the  psychoses 
due  to  syphilis,  which  he  found  were  divisible  into  the  following  classes:  (1)  irri- 
tative psychoses  based  on  cerebral  anemia  following  syphilitic  infection  even  from 
its  very  beginning:  (2)  simple  inflammatory  psychoses  due  to  meningitis  and  cere- 
bral softening;  (3)  neoplastic  psychoses  proceeding  from  cerebral  meningeal  gum- 
mata.     Griesinger  states  that,  when  acute  mental  disease  affects  patients  during  the 


^  James  G.  Kiernan,  Journal  of  ISTervous  and  Mental  Diseases,  July,  1880. 


41-i  EAELT    BEAIN    AXD    XEETE    SYPHILIS. 

secondary  stage  of  syphilis,  it  will  be  chiefly  those  whose  brain  is  organically  affected, 
who  have  previously  presented  symptoms  of  abnormal  cerebral  activity,  or  who  come 
from  neurotic  families. 

Wille  says  that  mental  symptoms  may  appear  two  months,  or  even  two  weeks, 
after  infection,  certainly  with  the  onset  of  the  secondary  symptoms.  Hildebrand  has 
had  very  similar  experience. 

Leubuscher  was  the  first  to  establish  the  existence  of  mental  symptoms  during 
the  secondary  period.  Prior  to  his  article  these  had  been  regarded  as  tertiary  acci- 
dents. 

Berthier  some  twenty-seven  years  ago  reported  several  acute  cases  of  insanity 
occurring  during  the  secondary  j^eriod.  Fournier  has  described  several  cases  of 
insanity  due  to  secondaiy  syphilis,  vaiying  in  type  from  confusional  insanity  to 
cataleptoid  states. 

Mickle  has  observed  several  cases  of  insanity  due  to  secondary  syphilis  in  which 
the  psychic  effect  of  syphilis  was  similar  to  that  of  alcohol.  Clouston  substantially 
agrees  with  Wille.  He  says  the  jDsychoses  occur  in  the  secondary  stage  of  the  dis- 
ease, coincidently  with  the  eruption,  and  are  curable  and  rare. 

C'adell  reports  a  case  characterized  by  mental  excitement  and  restlessness,  which 
reached  its  height  seven  months  after  the  initial  lesion  and  five  months  after  the 
appearance  of  the  secondaiy  symptoms,  with  the  onset  of  which  the  mental  symptoms 
began.  This  case  consisted  of  a  confusional  delirium.  The  patient  slept  but  little, 
but  rode  recklessly  about  at  night.  A  year  later  melancholia  had  set  in,  accompanied 
with  paralysis  of  energy,  so  that  the  patient  scarcely  left  his  bed.  He  at  length  made 
a  good  recovery. 

Regis  states  that  the  psychoses  of  secondary  syphilis  occur  on  the  appearance 
of  secondaiy  accidents  accompanied  with  fever,  principally  at  the  time  of  the  eruption. 
The  onset  is  more  or  less  brusque,  and  takes  the  form  of  acute  or  subacute  mania  or 
melancholia,  preferably  mania;  it  is  sometimes  of  a  circular  type.  It  is  usually  of 
short  duration,  disappears  with  the  febrile  manifestations  to  which  it  is  due,  and 
readily  yields  to  mercurial  inunction. 

Luys,  admitting  that  mania,  melancholia,  and  hallucinatory  confusion  can  occur, 
asserts  that  these  are  but  the  epiphenomena  of  a  morbid  process  in  evolution. 

Several  of  Kiernan's  own  cases  are  of  great  interest.  The  histories  of 
two  of  them  are  herewith  presented: — 

Case  1  was  that  of  a  35-year-old  Canadian,  a  periodically-drinking  tailor,  of 
criminal  antecedents  and  parentage.  A  sister  and  an  aunt  are  prostitutes.  One 
brother  is  idiotic  and  one  a  professional  burglar.  Foiu-  weeks  before  admission  he 
had  contracted  a  chancre,  which  healed  without  treatment.  Two  weeks  before 
coming  under  care  he  was  very  morose  and  irritable,  felt  chilly  sensations  all  over 
the  body,  and  was  very  languid.  Six  days  before  coming  under  care  he  was  attacked 
by  a  very  intense  fever,  and  on  the  following  day  complained  of  insects  crawling 
beneath  his  flesh,  and  of  men  being  at  the  Avindow  with  guns  to  shoot  him.  He  was 
markedly  terrified.  When  he  came  under  obserA^ation  he  had  a  temperature  of  104.9°. 
He  was  markedly  agitated,  constantly  in  motion,  and  had  an  expression  of  extreme 
terror. 

Sedatives  had  no  effect  on  the  mental  symptoms  of  the  fever.  On  the  third  day 
the  histoiy  already  narrated  was  obtained,  whereupon  mercurial  inunctions  were 
ordered.  During  the  following  night  the  patient  Avas  less  agitated,  but  retained  his 
delusions,  and  Avas  A'ery  little  inclined  to  remain  alone.  This  treatment  continued 
tAAO  days,  the  temperature  and  mental  state  remaining  the  same.  The  third  day 
after  this  a  roseolaceous  eruption  appeared  on  the  forehead  and  neck.     This  was  at 


EAELY  BEAI^'  AXD  XERVE  SYPHILIS.  415 

fii'st  a  simple  roseola,  but  in  twenty-four  hours  became  pustular  and  gradually  melted 
down  into  dark-brown  crusts,  flattened  and  depressed,  Avhich,  when  removed,  showed 
a  grayish  film  bathed  in  pus  underneath.  The  attendant,  soon  after  the  appearance 
of  the  eruption,  neglected  to  rub  in  the  mercurial  ointment,  whereupon  the  patient's 
temperature  rose  to  103.6°,  and  he  became  violently  excited,  rushing  wildly  from 
one  room  to  another,  saying  that  he  was  about  to  be  shot  and  that  spiders  were 
"eating  his  brain."  His  countenance  expressed  terror  and  he  was  always  in  motion. 
As  a  means  of  restraint  and  to  secure  treatment,  a  sheet  was  smeared  in  mercurial 
ointment,  the  patient  was  wrapped  in  this,  and  then  confined  in  a  camisole.  The 
next  day  his  temperature  fell  to  101.7°.  Although  still  retaining  his  delusions,  he  was 
much  more  at  ease  and  less  agitated  than  he  had  been  since  his  admission.  Treatment 
was  continued  three  weeks.  The  mental  disturbance  became  less  and  less  marked. 
The  eruption  began  to  cicatrize,  and  finally  healed  up  in  places,  leaving  thin,  red 
lines  radiating  from  the  center.  The  delusions  grew  less  and  less  vivid  until  they 
seemed  to  the  patient  but  dreams  of  an  unpleasant  nature  through  which  he  had 
passed.  He  retained  some  gruffness  and  irascibility,  but  this  was  evidently  natural 
to  him  and  not  insanity  of  manner.  He  made  a  good  recovery  and  remained  in 
good  health. 

Case  2. — A  baker,  25  years  old,  a  moderate  drinker,  had  a  brother  who  died 
insane  and  a  sister  under  treatment  in  an  insane  hospital.  When  he  came  under 
observation  he  was  very  much  agitated  and  had  well-marked  auditory  and  visual  hal- 
lucinations. He  saw  spiders  crawling  over  him,  and  guns  protruded  from  holes  in 
the  wall  to  shoot  him.  He  heard  wolves  and  lions  howling  and  roaring  at  him. 
He  kept  always  in  motion,  but  by  dint  of  great  effort  could  control  himself  and 
give  a  few  relatively  rational  answers  to  questions.  After  recovery  he  gave  the 
following  history:  Four  weeks  before  coming  under  treatment  he  had  contracted  a 
chancre.  About  the  beginning  of  the  fourth  week  after  this  he  had  a  distinct  chill, 
followed  by  a  high  fever.  Believing  this  to  be  the  onset  of  malaria,  but  feeling  unac- 
countably depressed,  he  took  10  grains  of  quinin  and  visited  Central  Park.  While 
there  he  was  so  frightened  at  the  howling  of  the  wolves  that  his  companion  was 
obliged  to  draw  him  away  to  avoid  attracting  attention.  This  scene  was  repeated 
before  the  lion's  cage.  He  was  not  afraid  of  the  animals,  but  of  their  howling.  On 
his  return  home  he  became  exceedingly  delirious  and  cried  out  about  wolves  and 
lions.  In  two  days  hospital  treatment  became  necessary.  On  admission  he  had  a 
temperature  of  104°.  He  Avas  fairly  well  nourished.  He  was  rather  loquacious,  which 
loquacity  was  at  times  broken  in  upon  by  his  hallucinations.  He  was  ordered  seda- 
tives as  in  the  previous  case,  also  without  effect.  The  fourth  day  of  treatment  a 
roseolaceous  eruption  made  its  appearance  on  his  forehead  around  the  roots  of  his 
hair.  The  patient  was  ordered  a  mercurial  ointment  applied  as  in  the  other  case.  In 
twenty-four  hours  his  temperature  fell  to  99.8°.  He  was  much  quieter,  but  retained 
his  delusions  and  hallucinations.  The  next  day  a  similar  eruption  to  that  described 
appeared  on  the  arms  and  trunk,  which  gradually  formed  flat  pustules.  These  became 
covered  with  greenish-brown  crusts,  which,  when  removed,  showed  a  grayish-red 
ulceration  beneath,  and  Avere  surrounded  by  a  copper-colored  areola.  The  delusions 
and  hallucinations  grew  less  viAid  for  the  next  two  Aveeks.  By  the  time  of  the  total 
disappearance  of  the  eruption  (at  the  beginning  of  third  Aveek)  they  disappeared  also, 
leaA'ing  the  patient  in  a  dazed  condition.  He  remained  relatiA^ely  stationary  for  about 
tAVO  Aveeks,  Avhen  he  gradually  brightened  up  and  reeoA'ered,  four  months  after  admis- 
sion. 


In  the  author's  opinion,  the  toxin  A'ieAv  of  such  cases  as  Kiernan's  is 
the  most  logical  one.    Indeed,  they  seem  to  he  typically  toxic.     An  insta- 


416  EAKLT    BKAIK    AXD    XERYE    SYPHILIS. 

bility  of  cerebral  structure  and  function,  moral  and  mental  influences,  alco- 
hol and  previous  cerebral  irritation  from  any  cause  whatever,  may  act  as 
factors  that  determine  the  toxemic  process  to  the  brain;  but  cerebral  in- 
toxication by  syphilitic  toxins  is  none  the  less  the  essential  factor. 

Some  cases  in  which  brain-symptoms  develop  a  year  or  two  after  the 
chancre  must  still  be  classed  as  early  psychoses  of  syphilis,  if  associated  with 
typic  secondary  lesions.  It  must  be  remembered,  in  this  connection,  that 
the  duration  of  the  disease  is  not  always  a  criterion  of  the  period  at  which 
the  evolution  of  syphilis  has  arrived.  Eruptions  characteristic  of  the  sec- 
ondary period  may  appear  very  early,  or  they  may  be  retarded  until  long 
after  their  usual  period  of  evolution.  The  point  to  which  the  evolutionary 
progression  of  S3q3hilis  has  arrived  is  often  a  better  criterion  of  the  patho- 
logic age  of  the  disease  than  the  period  of  time  since  infection. 


CHAPTER  XVIII. 

The  Period  of  Sequels,  oe  So-Called  Tektiart  Syphilis. 

Having  finished  the  description  of  the  lesions  of  the  secondary,  or 
active,  period  of  syphilis,  and  considered  the  physio-pathologic  explanation 
of  the  various  phenomena  presented  by  general  constitutional  infection  and 
localized  cell-accumulation,  it  now  remains  to  consider  the  period  of  sequels: 
the  so-called  tertiary  stage. 

The  Tubercular  Syphilide — Gummy  Infiltration.  —  One  of  the 
most  frequent  and  important  of  the  tertiary  lesions  or  sequels  is  the  tuber- 
cular eruption.  This  has  been  said  to  be  due  to  a  localized  accumulation  of 
morbid  cell-material  in  the  tissues — so-called  "gummy  infiltration" — that 
is  the  type  basis  of  all  tertiary  lesions.  This  gummy  material  is  termed  by 
Wagner  "syphiloma,"  and  is  described  by  him  as  an  infiltration  of  cells  and 
nuclei,  the  cells  not  being  capable  of  differentiation  from  the  normal  white 
blood-cell  or  leucocyte  and  the  nuclei  themselves  presenting  no  character- 
istic appearances.  He  states  that  their  morbid  effects  are  due  to  a  mere 
interference  with  the  function  and  nutrition  of  affected  parts  by  simple 
pressure.  Baumler  also  claims  that  the  histologic  elements  of  syjDhilomata 
lack  specific  microscopic  characters. 

The  tubercular,  or  gummy,  lesion  may  develop  in  any  situation,  its 
favorite  locations  being  the  cellular  tissue,  skin,  bones,  liver,  testes,  brain, 
and  kidneys,  and,  in  children  especially,  the  lungs.  This  gummy  material  is 
a  grayish -red,  homogeneous  mass  of  greater  or  less  consistency,  that  may  be 
found  in  the  parenchyma  of  any  organ  or  tissue  of  the  body,  either  as  a 
diffused  or  circumscribed  infiltration,  but  never  incapsulated.  When  this 
accumulation  of  morbid  material  is  superficial  and  exposed  to  unequal  press- 
ure, and  when  it  is  excessive  or  involves  the  walls  of  the  blood-vessels,  thus 
giving  rise  to  localized  innutrition  from  pressure  or  vascular  obstruction, 
the  whole  mass  is  liable  to  disintegrate  and  form  an  open  lesion,  or  break 
down  into  pus,  or  puruloid  material  that  may  absorb  through  fatty  or  gran- 
ular degeneration  without  ulceration. 

As  we  have  already  seen,  the  lesions  now  under  consideration  have  no 
specific  inoculable  properties,  this  view  being  supported  by  Eicord,  Diday, 
Barensprung,  and  Baumler.  This  is  the  only  difference,  so  far  determined, 
between  the  histologic  elements  of  the  tertiary  and  those  of  the  secondary 
lesions,  save,  perhaps,  the  greater  tendency  to  destruction  of  tissue  in  the 
former.  It  has  been  demonstrated  that  the  longer  the  duration  of  the  active 
period,  and  consequently  the  more  pronounced  the  changes  in  the  lymphatic 
structures  produced  by  its  lesions,  the  greater  the  liability  to  tertiary  lesions 

"  (417) 


418  PEEIOD    OF    SEQUELS. 

of  a  severe  type.  As  the  cells  composing  gummata  are  not  infectious  and  are 
less  active  than  the  true  sj^philitic  germinal  cell^  they  are  probably  not  the 
result  of  the  influence  of  an  active  infection  upon  the  normal  tissue-ele- 
ments, but  are  due  to  lymphatic  obstruction,  being  no  more  nor  less  than  an 
accumulation  of  normal  embryonal  cells  that  are  prone  to  undergo  and  pro- 
duce various  .degenerative  changes  through  nutritive  disturbances.  The 
Ij^mphatic  obstruction  giving  rise  to  this  accumulation  of  embryonal  cells  is 
probably  the  result  of  injury  to  the  absorbents  produced  by  the  lesions  of 
the  active  stage.  Eindfleiseh,  who  is  unexcelled  as  an  authority  on  patho- 
logic questions,  says: — 

"Luxurious  new  formations,  catarrhs  and  surface  secretions  of  various 
hinds  must  he  produced  when  the  lymph-conveyance  is  hindered." 

The  results  of  careful  investigation  tend  to  show  that  the  new  forma- 
tions and  surface  secretions  of  tertiary  syphilis  are  all  due  to  an  accumu- 
lation of  normal  germinal  material,  and,  if  this  be  true,  how  can  we  account 
for  it  except  by  the  existence  of  lymphatic  obstruction? 

The  author  accepts  this  view  of  mechanic  l3^mphatic  conditions  as  ex- 
planatory of  the  accumulation  of  lymphatic  germinal  elements  at  certain 
points,  but  believes  that  the  same  nervous  influence  lies  behind  some  sequelar 
lesions  as  has  been  suggested  in  explanation  of  the  phenomena  of  the  active 
period.  This  nervous  influence — trophoneurosis — is  more  difficult  of  ex- 
planation than  in  the  active  period,  for  the  germ  and  its  toxins  are  prob- 
ably gone.  Permanent  derangement  of  nervous  structure  and  function 
affecting  the  sympathetic  system  produced  b}^  the  lesions  of  the  active  stage 
is,  however,  a  rational  explanation.  Why  tertiary  lesions  should  occur  at  one 
time  rather  than  another  is  difficult  to  say.  Accepting  the  view  of  the  forma- 
tion of  the  gummata  or  syphilomata  that  has  been  set  forth,  the  term 
"gummy  period"  is  inaccurate.  The  term  "period  of  lymphatic  obstruc- 
tion," suggested  by  Otis,  is  more  comprehensive  because  indicating  the 
actual  pathologic  condition  and  the  exact  manner  of  its  production. 

After  the  removal  of  the  cells  by  fatty  degeneration  there  is  always  a 
tendency  to  recurrence.  This  explains  the  difficulty  of  curing  the  disease 
at  this  period.  This  tendency  is  due  to  an  increased  injury  to  the  lym- 
phatic structures  already  greatly  impaired  by  the  lesions  of  the  active  stage 
of  syphilis.  This  impairment  consists  in  the  formation  of  fibrous  tissue, 
as  a  result  of  low  inflammatory  action  mechanically  set  up  by  the  cells. 
This  fibrous  formation,  of  course,  interferes,  in  a  measure,  with  tissue- 
nutrition  in  diff'erent  localities,  by  producing  changes  in  the  vascular  walls. 
It  has  been  claimed  that  a  great  deal  of  the  trouble  in  so-called  tertiary 
syphilis  is  due  to  wide-spread  fatty  degeneration  caused  by  vascular  con- 
traction. In  any  event  these  vascular  changes  do  produce  innutrition  and  a 
tendency  to  destructive  changes  in  those  parts  supplied  by  the  affected 
vessels,  and  nutrition  is  still  further  impaired  by  local  pressure  from  accumu- 
lation of  lymphatic  elements. 


THE    TUBERCULAK    SYPHILIDE.  419 

It  is  well  known  that  fatty  and  purulent  degeneration  are  more  likely 
to  occur  in  some  subjects  than  in  others,  and  are  most  likely  to  supervene 
in  individuals  who  are  cachectic  or  debilitated  from  any  cause.  Debility 
would,  of  course,  be  produced  by  a  prolonged  and  severe  active  stage,  and, 
indeed,  Hutchinson  claims  that  "the  liability  to,  and  severity  of,  tertiary 
lesions  are  in  direct  j^roportion  to  the  duration  and  severity  of  the  secondary 
stage."     He  also  asserts  with  great  positiveness  that  tertiary  syphilis  com- 


Fig.  109. — Ulcerous  late  syphilide.     (After  Dumesnil.) 

prises  the  sequels  of  syphilis,  and  not  the  lesions  of  syphilis  proper.  The 
author  believes  there  are  some  sequels  that  are  not  due  to  lymphatic  obstruc- 
tion, and,  also,  that  there  are  many  apparent  exceptions  to  Hutchinson's 
rule.  The  most  important  exceptions  are  certain  phases  of  osseous  and  nerv- 
ous syphilis  that  will  receive  attention  later. 

The  practical  conclusion  at  which  we  may  arrive  after  a  careful  con- 
sideration of  all  the  facts  thus  far  presented  is  that  the  various  lesions  and 


420  PEEIOD    OF    SEQUELS. 

different  degrees  of  severit}^  of  tlie  plienomena  of  the  so-called  "tertiary 
stage  of  syphilis"  depend  upon  (1)  the  amount  of  damage  produced  by  the 
lesions  of  the  active  period  of  the  disease  and  its  duration,  (3)  the  con- 
stitutional condition  of  the  individual  independently  of  specific  infection. 

Late,  or  Sequelae,  Xeeve  and  Beain  Syphilis. — The  term  "nerv- 
ous syphilis"  has  been  applied  quite  generally  only  to  those  disorders  of 
brain  and  nerve — organic,  presumably — met  with  in  late  syphilis. 

The  nervoiis  lesions  of  late  syphilis  are  more  severe,  and  the  prognosis 
much  graver,  than  in  the  case  of  the  early  nerve-phenomena  discussed  in 
a  preceding  chapter.  The  reason  for  this  is  quite  obvious.  The  accumu- 
lation of  neoplastic  material  in  and  about  the  delicate  nerve-structures, 
occurring  in  late  syphilis,  is  associated  with  and  probably  dependent  upon: 
1.  The  local  damage  inflicted  by  the  lesions  of  the  active  stage  in  the  form 
of  a  low  grade  of  inflammation  with  connective-tissue  proliferation,  vascular 
and  lymphatic  obstruction.  2.  The  debilitating  effects  of  prolonged  sypli- 
ilization  and  the  prolonged  treatment  necessitated  by  it.  3.  Prolonged 
mental  worry,  with  or  without  alcoholic  or  other  excesses.  4.  In  some 
cases  resistance  to  remedies  occasioned  by  their  prolonged  use. 

It  is  probable  that  the  nerve  and  brain  lesions  of  the  sequelar  period  act 
entirely  by  producing  mechanic  and  nutritional  disturbance,  the  syphilitic 
infection  proper  having  long  since  become  exhausted.  What  role,  if  any, 
is  played  by  metabolic  toxins  is,  of  course,  problematic.  That  true  syphilitic 
toxins  are  no  longer  formed  the  author  believes.  Taking  everything  into 
consideration,  however,  the  disastrous  effects  and  unfavorable  prognosis  of 
late  nerve  syphilis  are  not  surprising. 

The  manifestations  of  sequelar  nerve  syphilis  are  many  and  various, 
although  the  local  lesions  are  tolerably  uniform  in  character  and  few  in 
number. 

Parah^ses — such  as  hemiplegia,  paraplegia,  and  monoplegias  of  different 
kinds — are  apt  to  occur,  and  are  due  either  to  localized  deposit  of  syphiloma 
external  or  internal  to  the  structure  involved  or  to  diffuse  interstitial  de- 
posits and  proliferation  of  obstructive  connective  tissue.  Gummy  tumors 
may  occur  in  the  brain  proper  or  its  membranes,  or  ihe  latter  ma}'  undergo 
a  chronic  thickening  resembling  chronic  meningitis  from  other  causes.  The 
pathologic  results  and  symptoms  produced  vary  with  the  location  and  func- 
tion of  the  structure  involved.  Gummy  deposits  in  and  about  the  vascular 
walls  interfering  with  the  cerebral  circulation  are  prolific  causes  of  paralysis. 
The  thickening  from  syphilitic  deposit  during  the  secondary  period  is  apt 
to  S0  pervert  the  nutrition  of  the  vascular  walls  that  atheromatous  and 
calcific  degeneration,  with  subsequent  rupture  and  apoplectic  effusion,  occur 
later  on  during  the  period  of  sequels.  This  same  vascular  degeneration  is 
often  the  cause  of  those  miliary  aneurisms  the  rupture  of  which  is  at  the 
bottom  of  many  cases  of  apoplexy  and  hemiplegia.  It  is  well  to  remember 
that  the  amount  and  severity  of  eruptions  experienced  in  the  active  period 


LATE  NERVE  AND  BEAIN  SYPHILIS.  421 

of  syphilis  is  often  inversely  to  the  danger  of  nervous  sequels.  Dumesnil, 
in  particular,  has  called  attention  to  this.^  The  disease  often  expends  its 
violence  upon  the  nervous  and  vascular  systems,  while  the  skin  and  mucous 
membranes  escape. 

The  various  cranial  and  spinal  nerves  are  likely  to  become  involved  in 
sequelar  syphilis.  This  involvement  may  be  central,  involving  the  brain 
origin  of  the  nerve,  with  or  without  a  greater  or  less  degree  of  coincident 
brain-involvement,  or  it  may  be  peripheral,  affecting  any  part  or  all  of 
the  distribution  of  the  nerve.  As  with  the  brain,  the  nerve-lesion  may 
consist  (1)  of  a  circumscribed  or  diffuse  gummy  deposit;  (2)  of  sclerotic 
changes  produced  (a)  by  lesions  of  the  active  period  or  (b)  by  sequelar 
gummy  deposit;    (3)  of  destruction  of  normal  tissue-elements. 

Sclerotic  changes — incidental  to  connective-tissue  proliferation  and 
contraction — and  destruction  of  normal  tissue-elements  are  the  explanation 
of  the  incurability  of  a  large  proportion  of  cases  of  nervous  disease  in  late 
syphilis.  Nutritional  perversions  incidental  to  permanent  disturbance  of 
lymphatics  and  blood-vessels  explains  the  tendency  to  relapse  in  cases  that 
apparently  yield  to  treatment — as  all  cases  do  prior  to  local  tissue-destruc- 
tion and  sclerosis.  This  point  emphasizes  the  necessity  of  haste  in  removing 
syphilomatous  nerve-deposits  by  proper  remedies.  Unlike  the  early  nerve- 
lesions,  which  23romptly  manifest  themselves  by  symptoms,  as  a  rule,  those 
of  late  syphilis  are  very  insidious,  and  may  do  great  and  irreparable  damage 
ere  symptoms  lead  to  their  detection. 

The  author  desires  to  emphasize  especially  the  fact  that  the  unyielding 
character  of  the  symptoms  may  mislead  as  to  the  diagnosis.  The  resistance 
of  the  symptoms  to  vigorous  treatment  is  often  taken  as  evidence  against 
syphilis.  The  consideration  of  the  permanent  damage — the  scarring,  so  to 
speak — produced  in  the  nervous  system  by  sequelar  syphiloma  shows  the 
fallacy  of  such  illogical  reasoning. 

A  special  predilection  for  the  nerves  of  special  sense  is  often  manifested 
in  syphilis.  The  author  has  at  present  under  observation  a  most  interesting 
case  of  permanent  anosmia,  coming  on  suddenly  in  a  syphilitic.  It  is  asso- 
ciated with  defective  taste. 

While  in  a  general  way  the  danger  and  severity  of  late  lesions  are  pro- 
portionate to  the  severity  of  the  active  stage, — as  has  already  been  re- 
marked,— it  is  none  the  less  true  that  in  some  cases  the  external  evidences 
of  syphilis  are  not  faithful  criterions  for  an  opinion  as  to  its  severity.  Exter- 
nal manifestations  may  be  slight,  the  disease  apparently  expending  its 
violence  upon  the  circulatory  and  lymphatic  systems.  This  explains  those 
otherwise-mysterious  cases  in  Avhich  objective  secondary  symptoms  are 
skipped,  yet  terribly-destructive  sequelar  lesions  develop  many  months  or 


^  Dumesnil  does  not  vouchsafe  an  explanation  of  the  phenomenon,  but  emphasizes 
the  clinical  fact. 


422  PEEIOD    OF    SEQUELS. 

even  years  later.     A  recent  case  of  the  author's  is  a  sad  and  instructive 
example  of  this: — - 

Case. — A  young  and  active  man  occupying  an  important  mercantile  position  con- 
tracted syphilis  for  which  he  was  treated  most  systematically  for  full  three  years  or 
more.  His  habits  were  unexceptionable.  During  the  treatment  he  was  absolutely  free 
from  symptoms  save  the  first  eruption  of  roseola,  a  few  mucous  patches  early  in  the 
case,  and  the  usual  amount  of  primary  and  general  adenopathy.  Being  apparently 
cured,  the  patient  passed  from  under  observation.  Ten  years  later  he  developed  neu- 
ritis of  the  right  brachial  plexus.  This  was  treated  by  a  distinguished  nerve-specialist 
as  rheumatism.  >Seven  months  later  cerebral  symptoms,  and  finally  general  paresis, 
develojjed.     Death  finally  occurred  despite  vigorous  antisyphilitic  treatment. 

Pressure  upon  a  nerve  or  nerve-center  produced  by  syphilitic  deposit 
may  give  rise  to  certain  special  symptoms:  e.g.,  joressure  upon  the  optic 
nerve  will  produce  blindness  of  the  corresponding  eye,  pressure  upon  the 
origin  of  the  olfactory  nerves  Avill  impair  the  sense  of  smell,  pressure  upon 
Broca's  center  will  produce  aphasia,  pressure  upon  the  fifth  cranial  or  its 
branches  will  produce  severe  neu.ralgia,  and  so  on  ad  infinitum.  Some  rare 
illustrations  of  nervous  sj'philis  are  noted  in  both  typic  and  precocious  cases 
of  the  secondary  period.     This  has  already  been  exhaustively  discussed. 

IxFLUEXCE  OF  SYPHILIS  0^^  THE  Spixal  Coed. — There  has  been  some- 
thing of  a  controversy  as  to  the  influence  of  syphilis  upon  the  spinal  cord. 
It  is  well  known  that  gummy  infiltration  and  localized  deposits  with  con- 
sequent paralysis  occur  in  the  cord,  but  the  etiologic  relation  of  syphilis  to 
locomotor  atax}^  has  been  disputed.  Erb  maintains  that  61  per  cent,  of 
cases  of  locomotor  ataxy  are  due  to  syphilis.  Fournier  claims  a  syphilitic 
origin  in  the  "enormous  majority  of  cases."  In  regard  to  this  question  the 
author  can  only  say  that,  while  the  statements  of  these  authorities  may  be 
exaggerated,  clinical  experience  seems  to  prove  that  quite  a  proportion  of 
cases  is  due  to  syphilis.  Taylor  opposes  this  view.  Beyond  doubt,  however, 
some  cases  are  curable  if  treated  early  by  the  iodids  and  merciiry.  The 
theory  of  the  causal  connection  of  syphilis  with  locomotor  ataxia  is  by  no 
means  new,  having  been  first  suggested  by  Duchenne  many  years  since.  It 
was  advocated  by  Yirchow,  Wunderlich,  and  Eomberg  at  least  thirty  years 
ago. 

The  principal  foundation  for  opposition  to  the  luetic  tlieory  of  tabetic 
etiology  is  the  incurability  of  the  majority  of  cases  of  locomotor  ataxy 
by  antisyphilitic  treatment.  This,  in  the  author's  opinion,  is  a  fallacious 
argument.  The  spinal  cord  is  a  very  delicate  structure,  and  it  does  not 
require  very  marked  nor  prolonged  j)athologic  changes  to  produce  perma- 
nent nutritional  changes  in  it.  As  has  been  already  stated,  it  is  probable 
that  insidious  nutritional  cord-changes  without  symptoms  in  the  active 
period  are  often  responsible  for  locomotor  ataxy  developing  in  the  period 
of  sequels.  The  peculiar  tendency  of  syphilis  to  produce  sclerotic  changes 
must  not  be  lost  sight  of.     Obviously,  treatment  relieves  symptoms  pro- 


TBOPHOXEUEOSIS    IN    SYPHILITIC    SEQUELS.  423 

diiced  by  syphilitic  toxins^  syphilized  cells,  and  true  syphiloma,  only  to 
the  extent  that  they  are  dependent  upon  nerve-empoisonment  or  neoplasmic 
deposit.     "Xerve-scars"  cannot  be  removed. 

Peognosis  of  Late  IsTeeve-lesions. — The  prognosis  of  late  nerve  and 
brain  syphilis  is  notoriously  bad,  but  in  many  cases  more  hopeful  than  some 
authorities  would  have  us  believe.  The  author  once  heard  an  eminent 
authority  say  of  a  serious  case  of  late  brain  syphilis:  "This  man  will  surely 
die  very  soon.  Such  cases  all  go  that  way."  But  the  patient  did  not  die. 
He  got  well  under  enormous  doses  of  iodids.  A  short  time  since  the  author 
saw  a  case  in  consultation  with  Dr.  Haerther,  of  Chicago,  that  illustrated 
this  point  very  forcibly: — 

Case. — The  patient  was  in  his  fourth  year  of  syphilis.  He  had  hemiplegia — with 
facial  jiaralysis — extensive  gummy  ulcers  on  the  extremities  with  bone-involvement, 
and  was  aphasic.  Emaciation  was  extreme,  and,  taken  altogether,  the  ease  was  most 
unpromising,  especially  as  treatment  had  not  so  far  been  well  tolerated.  An  unfavor- 
able prognosis  was  given,  with  the  proviso  that  the  ease  might  be  an  exception  to  the 
rule,  like  the  one  previously  described.  This  man  recovered,  and  when  last  seen  was 
apparently  as  healthy  and  hearty  as  could  be  desired. 

Teophoneueosis  in  Syphilitic  Sequels. — In  studying  some  of  the 
late  or  sequelar  lesions  of  syphilis,  particularly  those  involving  changes  in 
the  osseous  structures  of  the  head  and  face,  the  author  has  been  forcibly 
impressed  by  certain  characters  of  the  lesions  that  seem  to  depend  upon  a 
mere  occult  series  of  pathologic  changes  than  those  to  which  they  are  usually 
accredited.  Some  of  these  characteristics  pertain  also  to  many  of  the  lesions 
of  the  active  or  secondary  period  of  syphilis,  and  have  already  been  dis- 
cussed in  connection  with  the  syphilitic  fever,  roseola,  and  other  lesions. 

As  already  indicated,  the  relation  of  certain  syphilitic  phenomena  to 
organic  or  functional  disturbances  of  the  nervous  system — and  particularly 
the  S3anpathetic  system — is  manifested  here  and  there  along  the  whole  line 
of  morbid  phenomena  developed  by  the  disease. 

It  would  appear  that  syphilitic  infection  not  only  has  a  peculiar  affinity 
for  the  sympathetic  nervous  system,  but  that  this  affinity  is  particularly 
marked  in  the  case  of  the  upper  or  cervical  portion  of  the  sympathetic.  The 
proportion  of  lesions  aljout  the  head,  face,  and  mouth  is  relatively  much 
larger,  even  under  the  best  of  treatment,  than  in  other  portions  of  the  body. 
The  parts  supplied  by  the  fifth  cranial  nerve  appear  to  be  especially  sus- 
ceptible to  late  lesions,  although  the  nerve  itself  is  rarely  affected.  Most 
cases  met  with  in  private  practice  escape  general  cutaneous  eruptions  and 
bone-lesions  under  appropriate  treatment.  Few,  indeed,  no  matter  how 
thoroughly  they  may  be  treated,  are  not  affected  at  one  time  or  another 
with  lesions  of  the  oro-pharyngeal  mucous  membrane  and  alopecia  of  greater 
or  less  degree.  This  is  more  especially  true  of  the  active  period,  but  even  in 
the  late  and  sequelar  syphilides  this  same  predilection  for  the  structures  of 
mouth  and  throat  is  manifest.    Cases  are  frequently  met  with  in  which  the 


424  PEEIOD    OF    SEQUELS. 

initiatory  and  active  jDeriods  of  the  disease  have  been  passed  through  without 
serious  trouble,  when  suddenly  and  without  warning,  serious  destruction  of 
the  nasal,  palatal,  and  maxillary  bones  has  developed.  Many  cases  of  serious 
destructive  ulceration  of  the  pharynx  are  met  with  as  remote  manifestations 
of  syphilis  in  cases  in  which  lesions  have  been  escaped  during  the  earlier 
periods  of  the  disease. 

The  affinity  of  the  syphilitic  process  for  the  iris  may  possibly  be  ex- 
plicable from  the  important  function  of  those  filaments  of  the  sympathetic 
system  supplied  to  this  part.  In  other  words,  the  local  accumulation  of 
cells  in  the  iris  may  be  incidental  to  disturbance  of  nutrition  dependent 
upon  the  impression  of  the  syphilitic  infection  upon  the  central  sympathetic 
system. 

Even  in  congenital  syphilis  evidences  of  trophoneurotic  disturbance  are 
met  with.  The  peculiar  affinity  of  the  syphilitic  process  for  the  epiphyso- 
diaphysial  junction  of  the  long  bones  in  infants  and  children  is  strikingly 
suggestive.  It  is  here  that  the  processes  of  growth  and  nutrition  are  most 
active  and  tissue-building  most  rapid.  It  is  consequently  at  this  point  that 
disturbance  of  the  trophic  function  of  the  sympathetic,  which  presides  over 
the  physiologic  processes  of  nutrition  and  growth,  is  most  likel}^  to  be  mani- 
fested by  pathologic  change.  A  perversion  of  the  function  of  the  sympa- 
thetic would  result  in  imperfect  differentiation  of  the  cells  of  the  part,  and, 
as  the  rapidity  of  proliferation  of  cells  is  inversely  to  their  degree  of  dif- 
ferentiation, a  heaping-up  of  young  material  is  to  be  expected.  Associated 
with  this  imperfect  differentiation  of  cells  we  have  a  tendency  to  degenera- 
tion, for  it  may  be  formulated  that  the  tendency  to  degeneration  is  also  in 
inverse  ratio  to  the  degree  of  differentiation.  This  imperfect  differentiation 
with  consequent  tendency  to  degeneration  of  young  germinal  material  is 
the  characteristic  feature  of  all  lesions  and  all  periods  of  syphilis. 

The  physiologic  effects  of  the  remedies  upon  which  we  depend  for  the 
cure  of  syphilis  are,  so  far  as  they  go,  evidences  of  the  neurotic  element  in 
syphilitic  phenomena.  It  is  shown  that  mercury  and  potassic  iodid,  al- 
though very  efficacious,  are  in  no  sense  directly  curative,  their  beneficial 
effects  being  dependent  upon  their  power  of  inducing  fatty  degeneration  and 
elimination  of  the  neoplastic  and  toxic  products  of  the  syphilitic  process 
rather  than  upon  any  special  controlling  or  antidotal  effect  upon  the  poison 
per  se,  whether  this  poison  be  a  virus,  microbe,  or  infectious  cell.  The 
elimination  of  those  elements  of  the  infection  which  act  upon  the  nervous 
system,  may  be  the  all-important  factor  in  treatment.  In  reviewing  the 
opinions  of  our  best  syphilographers  regarding  the  treatment  and  prognosis 
of  syphilis,  one  is  impressed  with  the  idea  that  syphilis  is  a  disease  that 
runs  a  natural  course  in  spite  of  treatment,  the  physician  being  incapable 
of  doing  more  with  his  remedies  than  to  remove  the  effects  of  the  disease 
as  fast  as  they  appear, — i.e.,  melt  down  deposits,  neutralize  and  eliminate 
toxins, — thus  preventing,  so  far  as  possible,  permanent  damage  to  the  af- 


TEOPHONEUEOSIS    IN"    SYPHILITIC    gEQUELS.  425 

fected  tissues.  So  far  as  aborting  the  natural  course  of  the  disease  is  con- 
cerned, we  are  absolutely  helpless,  and  apparently  our  success  in  the  treat- 
ment of  the  disease  is  inversely  to  the  vigor  of  our  attempts  to  antidote  or 
"stamp  it  out/' 

If  the  neurotic  theory  of  the  modus  operandi  of  syphilitic  infection  be 
correct,  we  have,  in  our  efforts  to  discoverer  a  specific  remedy  for  syphilis, 
been  necessarily  led  away  from  those  lines  of  research  that  would  lead  to  a 
proper  therapeusis.  The  severity  of  the  results  of  syphilis  would  appear  to 
depend  (1)  upon  the  individual  susceptibility  of  the  nervous  system  of  the 
patient;  (2)  upon  his  constitutional  condition  at  the  time  of  infection  and, 
incidentally,  on  the  resisting  power  of  his  tissues;  (3)  upon  the  action  of 
remedies — this  being  by  no  means  the  most  important  consideration. 

Careful  observation  of  successive  crops  of  lesions  in  syphilis  shows  that 
the  tendency  to  destruction  of  tissue  and  involvement  of  various  important 
bodily  functions  increases  as  the  case  progresses.  We  see,  therefore,  in 
watching  a  case  from  its  inception,  the  gradual  supervention  of  a  trophic 
upon  a  vasomotor  disturbance,  and  as  the  case  progresses  this  trophic  aber- 
ration becomes  more  and  more  pronounced,  until  finally  in  the  period  of 
sequels  there  is  marked  tissue-destruction  in  various  situations — a  destruc- 
tion so  marked  as  to  have  led  to  the  belief  that  the  syphilitic  infection 
produces  in  such  instances  corrosion  of  the  tissue.  Inasmuch  as  the  in- 
fectious property  of  syphilis  decreases  as  the  case  progresses,  and  the  amount 
of  tissue-destruction  increases,  the  only  logical  explanation  of  the  serious 
effects  of  late  syphilis — in  the  admitted  absence  of  a  corrosive  power  of  the 
syphilitic  infection — would  seem  to  be  trophoneurotic  disturbance. 

Glancing  at  the  series  of  morbid  general  phenomena  occurring  in  a 
typic  case,  the  plausibility  of  the  trophoneurotic  theory  is  at  once  appar- 
ent: A  macular  eruption  or  perhaps  an  erythematous  efflorescence  of  the 
skin  first  develops,  which  is  but  slightly,  if  at  all,  raised  above  the  surface. 
This — the  roseola — does  not  produce  any  destruction  of  tissue,  nor  does  it 
contain  cell-deposit.  Later  on  papules  develop.  Next,  in  the  natural  order 
of  succession,  come  pustules,  perhaps  followed  by  ulceration.  Still  later, 
marked  ulceration  of  an  ecthjmiatous  or  perhaps  rupial  character  occurs. 
Interspersed  with  these  various  later  lesions,  or  occurring  alone,  there  may 
be  scaly  lesions — sometimes  tubercular  syphilides..  Coincidently  with  the 
papules  sore  throat  appears,  followed  later  on  by  mucous  patches,  and  per- 
haps mucous  ulceration.  As  the  case  progresses,  the  bones  may  be  affected; 
iritis  may  occur,  and  well  along  in  the  period  of  sequels  necrosis  of  the 
bones  may  develop.  It  will  be  found  that,  as  the  intensity  of  the  infection 
diminishes,  the  tendency  to  suppurative  processes  and  destruction  of  tissue 
increases.  The  later  lesions  are  found  to  be  frequently  associated  with  dis- 
turbance of  a  known  nervous  character,  cerebral  syphilis  in  its  various  forms 
being  quite  apt  to  occur. 

The  excejDtions  to  the  gradual  increment  of  severity  of  syphilitic  lesions 


426  PEBIOD   OF    SEQUELS. 

are  so  unusual  that  they  have  come  to  be  designated  as  precocious.  Malig- 
nant or  precocious  cases  of  syphilis  are  explicable,  in  the  author's  opinion, 
upon  the  theory  of  idios3^ncrasy  or  some  unknown  constitutional  condition 
that  enhances  susceptibility.  This,  again,  is  explicable  upon  the  ground  of 
peculiarit}''  of  nervous  structure. 

It  is  in  the  late  secondary  and  sequelar  lesions  of  the  disease  that  the 
apparent  trophoneurotic  character  of  syphilitic  manifestations  is  most  pro- 
nounced. The  author  has  long  been  impressed  with  the  peculiar  course  of 
some  of  the  osseous  lesions  of  late  syphilis,  particularly  those  affecting  the 
head  and  face.  The  destructive  effects  of  the  morbid  process  upon  the  bony 
tissue  seem  to  be  greatl)^  disproportionate  to  the  objective  and  subjective 
phenomena  that  precede  actual  destruction.  For  example,  the  objective 
l^henomena  preceding  the  necrosis  en  masse  of  various  portions  of  the  palate, 
superior  maxillar}^  and  nasal  bones  are  comparatively  slight  considering 
that  the  vitality  of  affected  bone  is  entirely  destroj'ed.  The  first  objective 
phenomena  in  necrosis  of  these  parts  are  incidental,  not  to  bone-death,  but 
to  Nature^s  attempts  to  rid  the  tissues  of  foreign  material.  The  greater  por- 
tion of  the  palate  may  be  destro3'ed  with  few  or  no  symptoms  until  sup- 
puration occurs.  The  first  symptom  is  likely  to  be  a  small  point  of  ulcera- 
tion of  the  superimposed  soft  parts,  and  the  discharge  of  a  small  quantity 
of  pus — a  quantit}'  entirely  disproportionate  to  the  extent  of  the  morbid 
process.  On  passing  a  probe  into  the  small  sinus  thus  formed,  a  large  por- 
tion of  the  bone  is  found  to  be  dead  and  perhaps  loose  in  the  tissues. 

It  will  be  found,  upon  observation  of  non-syphilitic  processes  that  pro- 
duce osseous  necrosis  or  caries,  that  bone-death  is  preceded  b}^  marked  ob- 
jective phenomena  in  the  way  of  pain,  swelling,  and  deformity — symptoms 
indicating  the  existence  of  proliferated  inflammatory  material  which  subse- 
quently produces,  by  simple  pressure,  destruction  of  the  vitality  of  the  bone. 
Those  syphilitic  processes  that  involve  bone  or  periosteum  early  in  the  dis- 
ease are  accompanied  by  relatively  more  prominent  objective  phenomena 
than  the  late  lesions  now  under  consideration;  yet,  at  the  same  time,  they 
are  rarely  followed  by  caries  or  necrosis.  Destruction  of  bone,  it  seems,  is 
reserved  for  the  late  secondary  or  sequelar  period  of  the  disease.  Thus,  it 
will  be  seen  that,  although  the  local  process  is  apparently  more  severe  in 
the  early  cases,  destruction  of  the  vitality  of  the  bone  is  not  so  likely  to 
occur.  There  is  a  marked  difference  between  the  nodes  and  diffuse  sub- 
periosteal swellings  of  early  syphilis,  and  the  condition  of  the  bone  and 
periosteum  that  precedes  necrosis  en  masse,  or,  for  that  matter,  caries,  in  the 
late  stages  of  the  disease. 

Besides  the  disproportion  between  the  degree  of  destruction  of  bone 
and  the  objective  phenomena  preceding  such  destruction,  another  sug- 
gestive point  is  the  fact  that  late  syphilis  possesses  the  power  of  dissecting 
out  definite  portions  of  osseous  tissue,  apparently  by  cutting  off  their  nutri- 
tive supph' — as  cleanly  as  it  could  be  done  by  the  knife.    Thus,  the  author 


TEOPHOXEUEOSIS    IN    SYPHILITIC    SEQUELS.  .  427 

has  numerous  specimens  of  the  intermaxillary  hone,  portions  of  the  alveolar 
process  of  the  maxillas,  the  malar,  and  the  ossce  nasi  which  became  necrosed, 
loosened,  and  were  removed  from  cases  of  late  sj^philis.  These  fragments 
of  bone  present  as  natural  a  conformation  in  most  instances  as  in  their 
healthy  condition. 

As  already  noted,  there  seems  to  be  a  special  predilection  of  late  syph- 
ilis for  the  parts  supplied  by  the  fifth  nerve,  indicating  that  the  ganglia  and 
filaments  of  the  sympathetic  system  presiding  over  these  parts  are  particu- 
larly sensitive  to  the  syphilitic  impression. 

In  some  instances  the  tendency  to  unilateral  destruction  of  osseous 
tissue  is  particularly  marked.  Thus,  the  palatal  process  of  the  superior 
maxilla,  or  the  alveolus  in  either  jaw,  may  necrose  and  give  way  without 
the  corresponding  portion  of  bone  becoming  affected.  Usually,  when  necro- 
sis attacks  the  facial  bones  it  is  im230ssible  to  check  it  until  the  line  of  de- 
markation  represented  by  the  anatomic  outlines  of  the  affected  bone  has 
been  reached. 

The  peculiar  manner  in  which  one-half  of  a  structure  may  be  dissected 
away  by  the  sequelar  lesions  of  syphilis  is  exem^olified  by  a  case  of  syphiloma 
of  the  tongue  that  recently  came  under  the  author's  observation  in  which 
unilateral  sloughing  of  the  organ  was  sharply  limited  by  the  raphe. 

In  several  of  the  author's  cases  the  portion  of  the  superior  maxilla  cor- 
responding to  the  intermaxillary  bone  was  dissected  out  by  the  sequelar 
syphilitic  process  with  loss  of  the  incisor  teeth,  the  remainder  of  the  jaw 
remaining  intact.  There  appears  to  be  a  peculiar  predilection  of  late  syph- 
ilis for  this  portion  of  the  jaw.  Caries  often  occurs  in  this  situation,  caus- 
ing the  loss  of  one  or  more  perfectly  healthy  teeth.  These  cases  appear  so 
characteristic  that  the  author  regards  loss  of  the  permanent  incisor  teeth 
without  apparent  cause  as  almost  positive  evidence  of  syphilis. 

The  following  case  illustrates  the  unilateral  limitation  of  some  late 
lesions  of  syphilis: — 

Case  1. — A  gentleman  of  30  had  an  obscure  history  of  syphilis,  dating  some  years 
back.  Several  years  before  coming  under  observation  ulceration  began  at  the  roots  of 
the  molar  teeth  upon  one  side  and  extended  inward  to  the  palate.  When  the  case  was 
first  seen  the  ulceration  had  extended  inward  upon  the  hard  palate  for  about  three- 
fourths  of  an  inch  and  forward  to  the  median  line,  where  it  abruptly  stopped.  The 
appearance  of  the  ulceration  was  quite  typie.  There  was  no  disease  of  the  teeth  or 
jaws  to  account  for  it.    Healing  was  rapid  under  appropriate  antisyphilitic  treatment. 

The  following  is  an  interesting  case  of  a  somewhat  similar  character: — 

Case  2. — A  gentleman  of  40  had  had  syphilis  seven  or  eight  years  previously. 
For  the  last  three  or  four  years  occasional  symptoms  of  the  disease  had  developed.  A 
few  months  since  ulceration  occurred  about  the  roots  of  the  upper  incisor  teeth.  This 
was  attended  with  slight  caries  of  the  intermaxillary  bone.  The  process  was  checked 
by  appropriate  treatment,  the  teeth,  which  were  loosened,  finally  becoming  perfectly 
solid.    About  six  or  eight  weeks  after  the  ulceration  was  healed  the  patient  consulted 


428  PEEIOD    OF    SEQUELS. 

the  author  for  supra-orbital  and  infra-orbital  neuralgia  and  hemicrania.  This  resisted 
all  treatment  except  antisyphilitic  remedies,  yielding  readily  to  potassie  iodid  in  large 
doses.  Within  a  few  days  the  patient  has  again  applied  for  treatment  for  paresthesia 
of  the  right  side  of  the  face  noticed  for  the  first  time  while  being  shaved.  His  face 
having  previously  been  excessively  tender,  he  soon  observed  the  lack  of  sensibility 
under  the  razor.  Associated  with  this  paresthesia  there  is  obscure  pain,  which  he 
locates  back  of  the  eyeball.  The  ensemile  of  symptoms  in  this  case  points  to  central 
disturbance  and  evidences  a  manifest  predilection  of  the  sequelar  lesion  for  the  fifth 
cranial  nerve. 

The  frequent  association  of  obstinate  tubercular  sypliilides  with,  late 
nervous  syphilis  is  striking.  It  seems  that  the  danger  of  involvement  of 
the  central  nervous  SA^stem  is  often  directly  proportionate  to  the  severity  of 
other  sequelar  lesions. 

In  considering  the  trophoneurotic  character  of  the  late  lesions  of  syph- 
ilis the  author  does  not  ignore  the  fact  that  syphilis  may  act  directly  upon 
the  nervous  system  in  several  different  ways,  which,  although  already  out- 
lined in  a  general  wa}',  will  bear  repetition: — 

1.  By  the  direct  effect  of  syphilitic  deposit  upon  the  nerve-cells  or 
nerve-fibers  or  membranes  of  the  brain  and  spinal  cord. 

2.  By  secondary  changes  in  the  brain  and  cord  membranes. 

3.  By  deposits  in  and  about  the  blood-vessels,  inducing  circulatory 
disturbance. 

4.  By  a  proliferation  and  condensation  of  interstitial  connective  tissue 
that  remains  after  the  syphilitic  material  per  se  has  been  removed. 

There  is  probably  a  difference  in  the  late  and  early  forms  of  syphilitic 
lesions  in  the  manner  in  which  the  trophoneurotic  element  is  brought  about. 
Thus,  it  ma}^  be  due,  in  order  of  succession  as  regards  the  period  of  the  dis- 
ease, (1)  to  a  direct  impression  of  the  syphilitic  poison  upon  the  sympathetic 
nervous  system;  (2)  to  direct  pressure  upon  the  nervous  structures  (late  sec- 
ondary and  early  sequelar  lesions);  (3)  to  a  disturbanoe  of  function  and 
nutrition  of  the  nervous  structures  incidental  to  interference  with  blood- 
supply  from  vascular  damage  done  at  an  earlier  period  (late  sequelar  lesions). 
This  division  is,  of  course,  not  arbitrar}",  but  is  fairly  practical. 

It  is  probable  that  mercury  acts  upon  the  nervous  system  in  very  much 
the  same  manner  as  syphilis.  It  is  very  difficult  to  differentiate  late  syph- 
ilitic lesions  of  the  bones  and  mucous  membranes  from  those  directly  due 
to  mercury.  That  mercur}'  exerts  a  powerful  effect  upon  the  sympathetic 
nervous  system  is  shown  by  ptyalism,  which  cannot  be  accounted  for  solely 
upon  the  theory  of  salivary  irritation.  The  well-known  power  of  mercury 
over  the  secretions  is  probably  due  to  its  influence  upon  the  S3''mpathetic 
ganglia.^  "When  the  injurious  action  of  mercury  is  superadded  to  syphilis, 
there  is  a  more  marked  tendency  to  trophoneurotic  phenomena  than  in  well- 


^  This,  of  course,  does  not  agree  with  Clevenger's  ingenious  theory  upon  this  par- 
ticular point,  as  will  be  noted  later. 


CLINICAL    STAGES    OF    SYPHILIS.  439 

treated  cases  of  the  disease.  Indeed,  the  excessive  use  of  mercury  often 
seems  to  determine  the  predilection  of  late  syphilis  for  the  bones  of  the 
head  and  face.  It  is  quite  as  capable  of  producing  necrosis  or  destructive 
ulceration  of  these  parts  as  is  syphilis  per  se. 

In  considering  the  question  of  trophic  disturbances  in  their  relation  to 
destructive  syphilitic  processes  it  is  well  to  again  remember  the  familiar 
physiologic  experiment  of  section  of  the  sympathetic  in  the  neck  of  the 
rabbit.  The  same  experiment  is  also  interesting  as  bearing  upon  the  faucial 
congestion  of  early  syphilis.  The  reddening  of  the  ear  of  the  rabbit  and  the 
inflammation  and  sloughing  of  the  cornea  incidental  to  section  of  the  sym- 
pathetic are  certainly  suggestive.  To  carry  the  analogy  of  this  physiologic 
demonstration  a  little  further,  the  serious  corneal  trouble  that  sometimes 
results  from  herpes  frontalis  seu  orbicularis  should  be  borne  in  mind. 

Positive  demonstration  of  the  dependence  of  the  phenomena  that  have 
been  outlined,  upon  nervous  disturbance,  is,  of  course,  difficult,  but  the  in- 
ferences drawn  appear  logical. 

Symptomatic  Division  of  the  Stages  of  Syphilis. — A  knowledge 
of  the  ordinary  division  of  syphilis  into  stages  is  essential  to  a  clear  clinical 
understanding  of  the  disease.  As  already  stated  in  a  general  way,  syphilis 
is  ordinarily  and  somewhat  arbitrarily  divided  into  the  so-called  "primary," 
"secondary,"  and  "tertiary  stages."  By  some  an  "intermediary"  stage  is 
described  which  comprises  the  lull,  or,  at  most,  the  period  of  almost  insig- 
nificant lesions  following  the  active  period,  and  preceding  the  development 
of  the  tertiary  stage.  Primary  syiDhilis,  of  course,  implies  the  initial  lesion 
with  its  attendant  glandular  enlargements — i.e.,  the  initiatory  period. 
Secondary  syphilis  comprises  the  earlier  affections  of  the  skin  and  mucous 
surfaces,  and  many  of  the  lighter  changes  in  the  eye,  testis,  and  other  glands, 
with  some  forms  of  nervous  phenomena — i.e.,  the  symptoms  of  the  active 
period  of  syphilis.  Tertiary  syphilis  comprises  the  later  severe  ulcerative 
skin-lesions;  the  deeper  lesions  of  connective  tissue,  bone,  muscle,  cartilage, 
and  viscera;  and  all  the  severe  lesions — i.e.,  sequelar  lesions — of  the  eye, 
testis,  and  brain;  in  short,  all  of  the  many  and  various  changes  characterized 
by  the  so-called  "gummy  deposit."  The  line  between  the  two  stages  is  not 
always  clear,  but  in  typic  cases  the  lesions,  at  first  superficial,  gradually 
increase  in  severity  until  the  destructive  pathologic  changes  of  the  so-called 
tertiary  stage,  or  period  of  sequels,  develop.  Some  of  the  lesions  properly 
belonging  to  the  secondary  group  are  liable  to  crop  out  with  the  tertiary 
lesions,  and  rarely,  on  the  other  hand,  nodes  develop  in  the  secondary  stage. 
Osseous  and  subperiosteal  swellings  do  develop  during  the  secondary  stage, 
but  characteristic  nodes  are  exceptionally  seen.  Quite  rarely  the  secondary 
stage  may  appear  to  be  omitted  entirely,  destructive  lesions  ordinarily 
characterizing  the  tertiary  period  appearing  within  a  few  months  after  the 
chancre.  These  varieties  of  cases  comprise  the  cases  of  so-called  irregular, 
precocious,  and  malignant  syphilis. 


430 


PEEIOD    OF    SEQUELS. 


Secondary  syphilis  lasts  often  a  year  and  sometimes  two  or  more. 

As  already  stated,  the  active  period  of  syj)hilis  has  a  duration  of  from 
eighteen  months  to  three  years,  hut  there  need  not  necessarily  be  any  mani- 
festations of  the  disease  during  that  time.  The  division  of  the  stages  or 
periods  of  S3^philis  involved  in  the  physiologic  pathology  of  Otis  is  based 
upon  the  sequence  and  character  of  the  pathologic  changes  altogether,  and 
not  upon  mere  symptomatology,  as  is  ordinarily  the  case.     It  will  be  seen, 


Fig.  110. — Squamous  syphilide — so-called  syphilitic  psoriasis — of 
palms.     (Author's  case.) 

therefore,  that  the  so-called  secondary  stage,  as  ordinarily  understood,  is 
merely  that  portion  of  the  active  period  during  which  actual  lesions  are 
present.  The  division  of  the  disease  into  primary,  secondary,  and  tertiary 
stages  depends  upon  the  form  of  the  lesions,  and  is,  therefore,  necessarily 
inaccurate  and  unscientific,  while  the  more  rational  division — ^^into  (1)  the 
initial,  (3)  the  active  periods,  and  (3)  the  sequelar  period — ^is  founded  upon 
a  knowledge  of  the  natural  course  of  the  disease  in  the  tissues,  the  lesions 
being  dependent  upon  this  natural  course,  and  not  vice  versa. 


CLINICAL    STAGES    OF    SYPHILIS. 


431 


Tertiary  syphilis — so-called — does  not  commence  until  one  year  after 
the  initial  sore,  excepting  in  cases  of  malignant  syphilis.  As  already  shown, 
it  is  not  a  necessary  stage  of  syphilis,  and  does  not  appear  in  by  far  the 
large  number  of  cases.  It  may,  however,  appear  after  years  of  apparent  good 
health.  The  whole  active — i.e.,  secondary — stage  is  sometimes  skipped, 
especially  under  treatment,  no  manifestations  of  general  syphilis  appearing 
until  suddenly  some  sequelar^t.e.,  tertiary — lesion  of  greater  or  less  severe 


Fig.  111. — Early  squamous  sypliilide — so-called  syphilitic  psoriasis- 
palms.     (Author's  case.) 


-of 


type  develops.  Such  cases  are  rare,  and  it  must  be  remembered  that  there 
is  a  possibility  of  even  some  of  these  being  due  to  the  excessive  administra- 
tion of  mercury. 

The  author  has  recently  seen  two  cases  of  extensive  gummy  ulcers  in 
which  three  and  nine  years,  respectively,  had  elapsed  since  the  primary 
sore,  during  which  time  no  secondary  symptoms  had  ever  appeared.  In 
another  case  a  man  presented  himself,  by  the  advice  of  his  physician,  for 
the  purpose  of  having  a  supposed  extensive  epithelioma  of  the  ]3arotid  region 


432  PEEIOD    OF    SEQUELS. 

removed.  This  proved  to  be  an  ulcerating  gumma,  and  was  completely 
cured  by  a  six  weeks'  course  of  the  iodids.  This  patient  had  had  a  chancre 
twenty  years  before  while  in  the  army,  but  from  that  time  until  the  gumma 
appeared  had  not  experienced  a  single  manifestation  of  the  disease. 

The  Syphilides. — The  most  prominent  of  the  manifestations  of 
syphilis  are  the  eruptions  of  the  skin.  These  are  termed  "syphilides/'  or 
"syphilodermata."  The  syphilides  are  many  and  various,  often  confusing; 
but  their  classification  may  be  rendered  quite  simple;  thus,  if  papules  are 
the  essential  feature  of  a  syphilitic  eruption  it  may  be  termed  a  "papular 
syphilide."  In  the  same  way  the  eruption  may  be  designated  as  vesicular, 
pustular,  tubercular,  scaly  or  squamous,  crustaceous  and  ulcerative  syph- 
ilides, and  such  combinations  as  papulo-pustular,  papulo-squamous,  and  so 
on,  the  first  part  of  the  combined  term  being  made  to  correspond  to  that 
feature  of  the  mixed  eruption  which  is  most  prominent.  Ulcerative  syph- 
ilides may  be  designated  as  superficial,  deep,  serpiginous,  or  perforative,  as 
the  case  may  be.^ 

The  principal  distinctive  lesions  of  syphilis  that  occur  at  various  periods 
during  its  course,  are:  macules,  papules,  mucous  patches,  mucous  tubercles, 
condylomata,  vesicles,  pustules,  bullse  or  blebs,  rhagades  or  fissures,  gummy 
tubercles,  and  diffuse  gummy  deposits  and  infiltrations.  Dependent  upon 
some  of  these  lesions,  different  forms  of  deep  and  superficial  ulceration, 
attended  or  followed  by  peculiarly-formed  crusts  and  scars,  may  occur — 
syphilitic  ecthyma  and  rupia — ulcero-crustaceous  syphilides.  Squama  or 
scales  in  various  forms  and  locations  may  develop. 

Physical  Characters  of  the  Syphilides. — The  most  important  point  with 
reference  to  the  syphilides  is  the  consideration  of  their  general  character- 
istics. These  characteristics  are:  (1)  polymorphism  of  all  lesions,  including 
the  chancre;  (2)  rounded  form  of  the  eruptive  lesions  and  ulcers;  (3) 
lividity  or  "ham  color,"  becoming  coppery,  then  grayish,  and  finally  white 
and  shining  as  cicatrization  occurs;  (4)  absence  of  pruritus  and  pain  ex- 
cepting in  hairy  regions,  and,  with  respect  to  pain,  in  the  bones;  (5)  svm- 
metry,  generalization  and  superficial  character  of  the  early  eruptions  in  all 
save  precocious  or  malignant  cases;  (6)  tendency  to  grouping  of  the  later 
eruptions,  which  involve  the  true  skin  and  tend  to  scarring;  (7)  tendency 
to  circular  arrangement;  (8)  scales  comparatively  thin,  white,  generally 
superficial  and  non-adherent;  (9)  crusts  irregular,  thick  and  adherent,  and 
either  of  a  greenish  or  black  color  from  admixture  of  disorganized  blood; 
(10)  abrupt  edges  of  both  skin  and  mucous  ulcerations,  which  are  not  under- 
mined, are  sluggish,  and  bleed  easily  (the  chancrous  ulcer,  it  will  be  remem- 
bered, has  sloping  edges):  (11)  the  rounded,  depressed  appearance  of  cica- 
trices, which  are  thin,  movable  upon  the  sublying  tissues,  pigmented  at  first 


^  Tide  Van  Buren. 


THE    STPHILIDES.  433 

sometimes,  but  eventually  becoming  white  and  shining.  These  scars  are 
often  crescentic  or  horseshoe  shaped. 

In  addition  to  the  foregoing  special  characters  of  the  lesions  of  syphilis 
we  have  attendant  symptoms,  such  as  the  so-called  syphilitic  fever  in  some 
cases,  alopecia,  headache,  osteocopic  pains  worse  at  night,  analgesia,  anes- 
thesia, indolent  lymphitis,  iritis,  sore  throat,  and  mucous  patches. 

The  term  "polymorphous"  is  applied  to  the  syphilides  because  there  is 
no  form  of  skin-lesion  that  may  not  occur  in  syphilis.  Indeed,  no  single 
form  or  type  of  lesion  is  usually  present:  e.g.,  a  papular  syphilide  is  rarely 
purely  papular,  vesicles,  pustules,  or  erythematous  patches  being  usually 
found  at  the  same  time,  and  the  eruption  being  named  from  the  lesion  that 
predominates. 

The  tendency  of  the  syphilides  to  arrange  themselves  in  a  rounded 
form  is  peculiar  and  well  marked,  the  later  syphilides  being  especially  dis- 
posed to  circular  grouping. 

The  color  of  the  syphilides  is  not  an  inflammatory  red,  but  is  a  vinous 
or  purplish  red,  resembling  the  color  of  raw  ham,  the  color  gradually  pass- 
ing by  pigmentation  into  a  coppery  hue,  or  more  deeply  to  a  brownish  or 
black  color.  The  pigmentation  may  last  for  years,  but  finally  clears  off 
gradually  from  the  center  toward  the  periphery,  the  cicatrix  or  spot  becom- 
ing eventually  white  and  shining. 

There  is  a  peculiar  feature  of  syphilitic  eruptions  that  is  often  of  value 
in  diagnosis.  It  will  be  found  that  the  syphilides  appear  more  prominent 
when  inspected  at  a  moderate  distance  than  when  the  patient  is  near  the 
eye.  The  author  has  frequently  demonstrated  this  singular  feature  of  the 
syphilides  to  his  classes  at  the  clinic,  and  it  has  been  readily  appreciated  by 
the  students.  When  an  eruption  of  syphilis  is  more  or  less  blurred  and 
indistinct, — as,  for  example,  when  mixed  with  acne, — the  patient  should  be 
asked  to  step  awa}^  ten  to  fifteen  feet.  It  will  be  found  that  while  the  sim- 
ple eruption  becomes  fainter,  the  syphilitic  lesions  stand  out  in  bold  relief, 
and  appear  larger  than  when  near  at  hand. 

The  papular  syphilide  sometimes  assumes  a  circinate  form  closely  re- 
sembling tinea  circinata,  or  ring-worm.  The  author  has  observed  this 
peculiar  form  in  several  instances.  In  one  case  the  eruption  was  situated 
upon  the  forehead  and  neck,  and  had  been  treated  for  ringworm;  in  an- 
other the  circinate  lesion  was  located  upon  the  hard  palate  and  subsequently 
became  transformed  into  an  ordinary  mucous  patch.  A  third  case  was 
recognized  as  a  cutaneous  syphilide  from  the  beginning.  Atkinson^  and 
Dumesnil  have  reported  similar  cases. 

Pain  and  pruritus  are  rarely  present  in  uncomplicated  syphilides,  ex- 
cepting when  irritated  or  inflamed.  In  dependent  portions  of  the  body,  as 
on  the  legs,  or  in  such  situations  as  the  throat,  which  are  subjected  to  con- 


^  I.  E.  Atkinson,  Journal  of  Cutaneous  and  Venereal  Diseases,  October,  1882. 

28 


434 


PEEIOD    OF    SEQUELS. 


stant  irritation,  ulcerations  are  liable  to  be  quite  painful.  When  an  eruption 
that  is  evidently  syphilitic  gives  rise  to  pain  and  itching,  we  can  usually  find 
some  cause  of  irritation  independent  of  the  syphilide.  The  patient  may, 
perhaps,  have  an  irritable  skin  and  a  pruritus  that  constantly  troubled  him 
prior  to  the  development  of  syphilis.  Contrary  to  the  general  rule,  how- 
ever, the  early,  eruptions  of  the  scalp  are  often  attended  by  pruritus.  The 
same  is  true  of  other  hairy  parts. 

The  earlier  syphilides  are  superficial,  leave  no  cicatrices, — save  when 
precocious, — and  are  symmetric,  appearing  upon  the  flanks  and  sides  of 
the  trunk,  the  sides  of  the  neck,  forehead,  etc.     The  later  eruptions  are 


Fig.  112. — Early  circinate  syphilide.     (Author's  case.) 


grouped  and  not  generalized,  and  are  characterized  by  destruction  of  tissue, 
as  evidenced  by  the  resulting  cicatrices.  They  may  leave  scars  even  if  no 
ulceration  occurs,  which  is  true  of  no  other  lesion  excepting  skin  tuber- 
culosis, of  which  the  lupus  non-ex&dens  is  an  example,  but  which  leaves  an 
irregular,  burn-like  scar,  totally  different  from  syphilitic  cicatrices.  In  some 
cases  of  lupus,  however,  the  scars  are  smooth.  The  scales  of  the  squamous 
syphilide  are  very  thin  and  non-adherent,  not  at  all  like  the  thick,  imbri- 
cated scales  of  psoriasis.  The  scabs  of  the  ulcerative  syphilides  are  thick, 
rough,  and  adherent;  dark,  of  a  greenish-black  color  usually,  but  sometimes 
pale  if  the  lesion  be  simply  pustular. 


THE    SYPHILIDES. 


435 


Two  important  varieties  of  nlcero-crustaceous  syphilide  are  syphilitic 
ecthyma  and  syphilitic  rupia.  The  first  consists  in  an  eruption  of  large 
pustules  that  soon  scab  over  with  a  characteristic  dark-greenish  crust.  On 
lifting  this  crust  a  characteristic  sharply-cut  circular  ulcer  will  be  found. 
Syphilitic  rupia  is  an  advanced  stage  of  the  same  ulcerative  process,  in 
which  as  the  crusts  form,  they  are  pushed  up  and  replaced  by  accumulations 
of  material  from  beneath,  and,  the  ulceration  gradually  extending  at  its 
periphery,  the  lesion  soon  presents  a  peculiar  appearance,  quite  like  an 
oyster-shell  upon  the  skin.  The  crusts  are  piled  up  in  imbricated  layers, 
which  when  lifted  from  their  bed  expose  the  results  of  tissue-destruction 


Fig.  11.3. — Circinate  syphilide.     (Author's  case.) 

in  the  shape  of  extensive  ulceration.  These  rupial  crusts  may  become  very 
large,  and  when  numerous  form  a  most  disgusting  spectacle.  The  pustular 
and  ulcerative  skin-lesions  in  rare  cases  become  phagedenic,  perhaps  serpig- 
inous, constituting  a  very  formidable  condition.  Death  may  result  from 
exhaustion  in  such  cases.  Eruptions  of  this  kind  are  most  apt  to  follow 
phagedenic  chancre,  not  because  of  intensity  of  infection,  but  from  inherent 
lack  of  vital  resistance. 

It  has  already  been  stated  that  the  ulcerations  of  syphilis  are  round, 
clear  cut,  and  not  unlike  chancroid.  They  are  sluggish  like  any  chronic 
ulcer,  and  painless,  unless  greatly  congested  and  inflamed,  or  located  over 
a  bone  the  periosteum  of  which  is  involved. 


436 


PEEIOD    OF    SEQUELS. 


Cicatrices  remaining  after  destruction  of  tissue  by  the  syphilides, 
whether  there  has  been  ulceration  or  not,  are  usually  rounded,  thin,  de- 
pressed, and  movable,  not  adherent.  They  are  at  first  pigmented,  especially 
in  brunettes,  but  eventually  clear  up  and  become  white  and  shining.  In 
strumous  subjects,  in  whom  the  lesion  is  likely  to  be  a  combination  of  struma 
and  syphilis,  tlie  resulting  cicatrices  are  apt  to  be  puckered  and  irregular. 
They  are  often  cribriform,  on  account  of  the  persistence  of  ducts  in  the 
affected  skin  and  the  extreme  tenuity  of  the  lesion.  In  some  cases  they  are 
horseshoe  or  crescentic  shaped. 

DuEATiON  or  Syphilis. — There  is  no  disease  the  duration  and  course 


Fig.  114. — Ulcerous  late  syj^hilide.     (After  Dumesnil.) 


of  which  are  so, uncertain  as  those  of  syphilis.  It  is  impossible  to  state 
arbitrarily  in  any  given  ease  that  the  disease  has  or  has  not  terminated. 
This  is  more  especially  true  when  we  consider  that  it  may  permanently 
modify  the  constitution  of  the  individual,  even  though  no  typic  manifesta- 
tions of  the  disease  appear  after  a  certain  time.  None  of  the  methods  of 
blood-examination  thus  far  suggested  to  determine  the  existence  of  syphilis 
have  proved  reliable.  The  disease  may  manifest  itself  as  a  series  of  mild 
secondary  eruptions  followed  by  apparent  recovery,  or  it  may  afford  no 
evidence  of  its  presence  after  the  initial  sore  until  late  in  life,  when  suddenly 
tertiary  lesions— 7. p.,  sequels — crop  out. 


CURABILITY    OF    SYPHILIS. 


437 


CuEABiLiTY  OF  SYPHILIS.- — Although  it  must  be  acknowledged  that  in 
a  large  number  of  cases  syphilis  causes  a  permanent  modification  of  the 
patient's  constitution,  still  the  evidence  shows  that  syphilis  can  be  cured. 
In  the  author's  opinion  it  is  a  perfectly  curable  affection  in  by  far  the 
greater  proportion  of  cases,  providing  the  patient  be  intelligent  and  the 
physician  conscientious.  We  have  proof  of  this  in  the  cases  of  second 
attacks,  cited  by  reliable  authorities,  and  we  have  'already  seen  that  what- 
ever the  possibilities  of  tertiary  lesions,  they  are  not  necessary  and  are  un- 
doubtedly sequels.  It  has  been  found  that  patients  with  sequelar  syphilis 
may  procreate  healthy  children,  and  that  the  blood  and  secretions  of  tertiary 
lesions  are  no  longer  inoculable.  If  the  microbial  character  of  syphilitic  in- 
fection be  admitted,  the  spontaneous  tendency  to  cure  of  syphilis  is  almost 
beyond  controversy.    It  is  part  of  the  life-history  of  the  germ. 


Fig.  115. — Secondary  circinate  syphilide.     (After  Dumesnil.) 


As  found  among  the  better  classes,  syphilis  is  often  a  very  insidious  dis- 
order. We  often  meet  with  respectable  women  complaining  of  various 
symptoms,  vaguely  described  and  as  vaguely  treated  as  neuralgic  or  rheu- 
matic, that  are  no  more  nor  less  than  slight  manifestations  of  this  jorotean 
disease  and  by  which  the  patient  perhaps  comes  honestly  enough.  Children 
may  have  obscure  symptoms  that  mislead  both  parents  and  physician,  and 
are  conveniently  termed  "scrofula"  in  some  instances.  Paterfamilias  for- 
gets a  "little  sore"  that  he  once  had,  and  never  dreams  of  attributing  the 
ailments  of  his  wife  and  children  to  those  dimly-rememljered  and  as  lightly- 
weighed  wild  oats  that  he  once  sowed.  But,  whether  remembered  or  not, 
the  harvest  garnered  as  the  fruit  of  that  sowing  is  none  the  less  certain. 

When  may  a  Syphilitic  Marry? — The  practical  question  now  arises: 
"When  is  it  safe  for  a  person  to  marry  after  having  had  a  chancre?"     Our 


438  PEEIOU    OF    JiEQUELS. 

best  authorities  assert  that,  on  the  average,  marriage  is  safe  at  the  end  of 
three  years.  More  rationally,  from  a  clinical  stand-point,  the  period  may 
be  fixed  as  eighteen  months  after  the  disappearance  of  the  last  syphilitic 
lesion,  providing  three  years  have  elapsed,  the  patient  being  meanwhile 
nnder  careful  treatment  that  is  to  be  persisted  in  until  after  the  birth  of 
the  first  child..  During  the  three  years  of  probation  symptoms  may  crop  out 
at  any  time,  but  under  careful  management  they  are  usually  slight,  and, 
whether  we  can  Justly  claim  a  cure  or  not,  the  virulence  of  the  disease  seems 
to  be  exhausted  in  cases  of  mild  or  moderate  severity  so  managed  in  about 
three  years.  If  the  patient  be  addicted  to  excesses  of  any  kind,  if  he  does 
not  take  a  steady  and  efficient  course  of  treatment,  but  treats  himself  or  is 
treated — perhaps  to  excess — at  spasmodic  intervals,  his  chances  are,  of 
course,  not  very  good.  Fournier  gives  the  following  requirements  for  the 
guidance  of  syphilitics  contemplating  marriage^: — 

1.  Present  freedom  from  specific  symptoms. 

2.  Advanced  period  of  the  disease. 

3.  A  considerable  period  of  absolute  freedom  from  symptoms  since  the 
last  specific  manifestation. 

4.  A  mild  type  of  the  disease. 

5.  Prolonged  and  thorough  treatment. 

These  requirements  contain  in  a  few  words  all  that  it  is  necessary  for 
us  to  impress  upon  syphilitic  patients  who  consult  us  with  reference  to  their 
matrimonial  prospects.  Should  they  refuse  to  be  guided  by  the  physician, 
the  responsibility  must  rest  upon  their  own  consciences.  It  is  tmfortunate 
that  so  many  persons  are  willing  to  assume  so  grave  a  responsibility.  A 
man  who  Avill  deliberately  condemn  an  innocent  woman  to  the  dangers  of 
syphilitic  infection  is  beneath  contempt,  yet  such  men  are  met  with  in  the 
practice  of  every  physician. 

In  the  case  of  women,  a  still  longer  period  of  probation  should  be  en- 
joined. The  syphilized  female  is  much  more  dangerous  to  the  offspring 
than  the  male.  It  is  fortunate,  perhaps,  that  syphilis  in  the  mother  so  often 
causes  her  to  abort,  thus  preventing  great  disaster.  Sooner  or  later,  how- 
ever, she  is  liable  to  bear  a  living  child,  and  this  child  will  almost  inevitably 
show  signs  of  syphilis  of  a  greater  or  less  degree  of  severity. 

The  author  desires  to  state,  in  passing,  that  the  ph3^sician  should  never 
give  a  patient  assurance  of  absolute  safety  in  marriage.  Under  no  system 
of  treatment  can  there  fail  to  be  an  element  of  doubt.  This  should  be 
plainly  stated  to  the  patient.  The  author  has  had  but  one  case  in  which 
a  patient,  well-treated  and  without  symptoms  for  over  three  years,  claimed 
to  have  infected  his  wife  shortly  after  marriage,  and  in  that  case  there  was 
probably  deceit  on  the  part  of  one  or  the  other  of  the  contracting  parties. 
The  bare  possibility  of  such  a  case,  however,  should  make  us  conservative. 


^  A.  Fournier:    "Syphilis  et  Mariage." 


PEOGNOSIS    OF    SYPHILIS.  439 

Peognosis  of  Syphilis.  — •  The  severity  of  syphilis  depends  mainly 
upon  the  constitution  and  hygienic  condition  of  the  patient.  As  we  have 
seen,  we  do  not  have  at  the  present  day,  as  a  rule,  such  severe  cases  as  in 
former  years.  In  the  better  classes  it  is  a  very  mild  disease  by  comparison 
with  the  lower  walks  of  life,  in  which  we  still  meet  with  frequent  cases  exem- 
plifying its  serious  character.  Even  among  persons  who  are  constitutionally 
and  hygienically  well  circumstanced,  we  sometimes  see  cases  of  the  most 
malignant  type,  as  illustrated  by  the  following  case: — 

Case. — A  fine-appearing  and  exceptionally  well  nourished  man,  whose  ciix-um- 
stances  were  the  very  best  that  could  be  desired,  consulted  the  author  in  regard 
to  a  small  abrasion  upon  the  glans  penis.  This  had  appeared  a  day  or  two  after  a 
suspicious  exposure  and  had  probably  resulted  from  friction  during  intercourse.  He 
was  told  that,  while  the  sore  had  nothing  at  all  alarming  about  it,  it  would  bear 
close  watching.  At  the  end  of  two  weeks  from  the  date  of  exposure  the  sore  became 
slightly  indurated,  constituting  the  parchment  variety  of  chancrous  induration.  This 
chancre  disappeared  in  a  very  short  time,  but  was  followed  by  a  most  malignant  course 
of  syphilis.  Apparently  tubercular  lesions  appeared  in  various  situations,  and  deep 
ulcerations  developed  and  ran  their  course  inside  of  three  months,  the  patient  barely 
escaping  with  his  life. 

The  severity  of  the  syphilitic  infection  cannot  be  prophesied  from  the 
character  of  the  primary  sore.  The  foregoing  case  serves  as  a  very  forcible 
illustration  of  this  observation.  Cases  of  this  sort  are  seldom  seen  in  private 
j)ractice,  and  only  those  practitioners  who  are  so  fortunate  as  to  enjoy  the 
privileges  of  the  large  general  hospitals  are  likely  to  realize  the  severity  of 
syphilis  in  its  more  marked  and  serious  phases. 

The  following  cases  illustrate  the  occurrence  of  obstinate  solitary  lesions 
of  a  peculiar  or  severe  character,  in  occasionah  cases  of  syphilis  under  the 
most  careful  management: — 

Case  1. — The  author  was  consulted  by  a  young  man  in  good  circumstances, 
24  years  of  age,  in  regard  to  a  genital  lesion  that  was  apparently  chancroid. 
This  healed  in  about  two  weeks;  but  about  the  second  week  thereafter  induration 
appeared  in  the  cicatrix.  This  was  followed  by  a  t}T)ic  roseola,  but  there  has  never 
appeared  a  lesion  of  the  skin  or  mucous  membranes  since,  with  the  exception  of  the 
lesion  about  to  be  described:  About  two  years  after  the  contraction  of  syphilis,  and 
at  a  time  when  he  was  still  under  treatment,  his  tongue  began  to  trouble  him.  The 
lingual  mucous  membrane  became  greatly  thickened  and  fissured,  constituting  the  con- 
dition known  as  "syphilitic  psoriasis  of  the  tongue."  This  persisted  in  spite  of 
treatment  for  some  months,  when  it  finally  yielded  to  hydrotherapy  and  large  doses 
of  iodids. 

This  case  is  interesting  from  the  fact  that  the  lingual  lesion  was  the 
only  source  of  discomfort  during  the  entire  course  of  the  constitutional  dis- 
ease. 

Case  2. — This  is  similar  to  the  preceding  case,  so  far  as  the  lingual  lesion  is  con- 
cerned, but  differs  from  it  in  that  the  patient  has  been  afl^icted  with  alopecia,  severe 
mucous  patches,  tubercular  and  squamous  syphilides,  and  severe  nodes,  with  their 
accompanying  osteocopic  pains.  This  patient  is  28  years  of  age  and  has  been  afflicted 
with  syphilis  for  ten  years.     He  has  taken  the  best  of  care  of  Jiimself,  being  treated 


440  PEEIOD    OF    SEQUELS. 

off  and  on  for  the  entire  period  since  he  first  contracted  the  disease.  He  has  done 
well  under  systematic  treatment  -with  the  exception  of  lesion  of  his  tongue,  and  this 
absolutely  refuses  to  yield  to  treatment.  Prolonged  residence  and  treatment  at  Hot 
Springs  has  been  of  little  or  no  service.  The  administration  of  iodids  in  tremendous 
doses  does  not  affect  the  lesion  appreciably,  and  mercury  is  not  tolerated  at  all.  The 
microscope  does  not  show  malignancy. 

Case  3. — In  this  case  thorough  treatment  has  been  giA-en  continuously  for  two 
years,  and,  until  recently,  with  apparent  success.  Within  a  few  weeks,  however, 
syphilitic  onychia  of  the  left  index  finger  and  the  great  and  little  toes  of  the  right 
foot  has  appeared,  and  bids  fair  to  prove  exceedingly  obstinate. 

Case  4. — This  gentleman  Avas  referred  to  the  author  by  Dr.  S.  S.  Vaughn,  of 
Hot  Springs,  where  he  had  been  sojourning  for  six  weeks.  He  had  improved,  but  the 
case  was  at  a  stand-still  and  the  patient  was  obliged  to  come  home.  At  this  time 
he  had  tibial  osteitis  and  several  large  gummy  ulcers  of  the  leg  that  were  excessively 
painful.  Treatment  had  been  continuous  for  over  a  year,  but  with  little  effect.  Large 
doses  of  iodids  finally  brought  about  recovery  of  the  lesions  and  the  case  is  now 
doing  well. 

Case  5.- — A  young  married  Avoman  contracted  syphilis  tAvo  years  ago  and  has 
been  under  treatment  CA'er  since.  She  has  had  a  typic  .  course  of  syphilis,  Avith 
about  all  of  the  secondary  lesions  possible.  She  is  noAv,  for  the  first  time  since"  its 
commencement,  apparently  free  from  symptoms  of  the  disease.  Little  or  nothing, 
howeA^er,  can  be  claimed  for  her  treatment.  Perhaps  the  case  may  have  been  Avorse 
without  it,  but  that  is  doubtful. 

x^lthough,  as  just  stated,  it  is,  as  a  rule,  impossible  to  predict  the  se- 
verity of  syphilis  from  the  character  of  the  primary  sore,  this  statement  re- 
quires some  qualification:  e.g.,  in  cases  of  phagedenic  chancre  a  severe  course 
of  syphilis  is  to  he  expected,  not  because  of  any  intrinsic  severity  of  the  in- 
fection, hut  because  the  constitution  is  at  fault.  This  constitutional  per- 
version will  have  the  same  influence  upon  the  general  symptoms  as  upon 
the  primary  lesion  in  inducing  phagedena.  It  is  probabl3\  as  previously 
suggested,  some  peculiar  condition  of  trophoneurotic  instability  of  nutri- 
tion, ycleped  by  courtesy  "idios3mcrasy." 

The  character  of  the  earlier  eruptions  should  influence  the  prognosis 
somewhat.  The  milder  and  more  insignificant  these  are,  the  more  benign 
the  subsequent  course  of  the  disease  is  apt  to  be,  and  vice  versa.  This  is 
exemplified  in  cases  of  malignant  syphilis,  in  which  the  earlier  lesions  are 
deep  and  destructive.  Vesicular,  and  more  especially  pustular  eruptions, 
indicate  a  severer  type  of  the  disease  than  do  papular  and  erythematous 
lesions. 

In  considering  this  point  it  is  to  be  remembered  that  generalization  and 
severity  are  two  different  -qualities  of  syphilides.  Thus,  a  severe  type  of 
lesion  may  be  scanty  in  number,  while  a  mild  t3^pe  may  be  generalized  and 
abundant.  Serious  nerve  and  brain  lesions  are  more  apt  to  occur  where 
the  S5^philides  are  discreet  and  of  severe  type  than  where  they  are  both  severe 
and  abundant.  The  author  believes  that  DumesniFs  view,  already  pre- 
sented, is  really  intended  to  cover  this  point,  although  that  gentleman  does 
not  explicitly  so  state. 


EELATION    OF    SYPHILIS    TO    CAJ^TCEE.  441 

The  BeJation  of  Syphilis  to  Malignant  Disease. — The  possibility  of  a 
combination  of  late  syphilis  and  carcinoma  has  recently  suggested  itself  to 
the  profession.  It  has  even  been  claimed  in  certain  quarters  that  trans- 
formation of  a  syphilitic  into  a  cancerous  process  is  possible.  The  first  cases 
of  combined  cancer  and  syphilis  were  reported  by  Jonathan  Hutchinson, 
and,  following  him,  Langenbeck  directed  attention  to  this  unusual  class  of 
cases.  Lang,  of  Vienna,  recently  exhibited  a  very  interesting  case  of  this 
kind: — 

Case. — A  middle-aged  woman  had  suffered  from  syphilis  for  a  protracted  period. 
Scars  of  former  syphilitic  processes  were  present  upon  the  trunk  and  face,  the  palate 
being  perforated  and  the  upper  lip  having  suffered  considerable  loss  of  substance.  At 
the  time  she  came  under  observation  most  of  the  ulcers  were  cov^ered  with  a  white 
scab,  the  histologic  examination  of  which  did  not  reveal  any  sign  of  diagnostic  im- 
portance. About  a  month  later,  however,  a  small  white  indolent  ulceration  appeared 
upon  the  hard  palate.  A  small  portion  of  the  involved  tissue  was  excised  and  upon 
microscopic  examination  was  found  to  be  epithelioma.  Lang  states  that  he  had 
observed  three  other  very  similar  eases,  the  development  of  the  carcinoma  upon  the 
syphilitic  soil  being  demonstrated  in  each  instance  by  microscopic  examination.  The 
first  ease  that  came  under  his  observation  had  suffered  from  a  characteristic  course 
of  syphilis,  including  numerous  relapses  of  iritis  and  gummatous  ulcerations  that 
had  cicatrized  with  the  exception  of  one  which  became  transformed  into  a  "cancroid" 
of  the  skin.  The  second  case  was  that  of  a  man,  aged  46,  who  had  suffered  from 
various  syphilitic  ulcerations  on  different  parts  of  the  face  and  body.  After  anti- 
syphilitic  treatment  one  ulcer,  located  beneath  the  tongue,  proved  resistant  to  treat- 
ment and  became  transformed  into  cancer.  In  the  third  case  a  syphilitic  infiltration 
located  in  the  lower  lip  underwent  a  relapse  at  the  end  of  a  year  and  assumed  a 
carcinomatous  character. 

It  is  unfortunate  that  the  profession  has  not  more  carefully  noted  the 
cases  in  which  carcinoma  has  developed  in  syphilitics.  There  are  many 
cases  in  which  careful  study  might  demonstrate  the  causal  relation  of  syph- 
ilis to  malignant  disease. 

A  case  that  the  author  had  the  opportunity  of  observing  was  one  the 
progress  of  which  he  had  studied  for  a  protracted  period;  hence  there  is 
no  doubt  as  to  the  primary  condition  upon  which  the  malignant  disease 
that  eventually  destroj^ed  the  patient^s  life  was  ingrafted.  In  recognizing 
the  transformation  of  syphilitic  processes  into  cancer,  the  author  does  not 
wish  to  be  understood  as  claiming  that  the  histologic  elements  of  syphilis 
are  ever  transformed  into  those  characteristic  of  cancer,  but  that,  the  ele- 
ments of  syphilis  having  been  removed,  the  tissues  are  left  in  such  a  dam- 
aged state  that  continued  irritation  may  result  in  cancerous  degeneration. 
On  the  other  hand,  a  syphilitic  process  may  recur  so  frequently,  and  be  so 
obstinate  to  treatment,  that  the  irritation  thereby  produced  is  capable  of 
causing  cancer. 

It  is  as  yet  too  soon  for  us  to  discuss  the  question  of  the  existence  of 
special  bacilli  in  syphilis  and  cancer  for  the  purpose  of  disproving  the  pos- 
sibility of  the  transformation  of  the  one  into  the  other.    It  is  conceivable 


443  PEBIOD    OF    SEQUELS. 

that  both  cancerous  and  syphilitic  deposits  may  act  in  the  same  manner  as 
other  irritating  processes  in  the  tissues.  It  is  to  he  presumed  that,  if  a  can- 
cer were  present  in  the  month  of  a  syphilitic  subject,  syphilitic  processes 
would  be  more  apt  to  develop  in  the  vicinity  of  the  malignant  disease  than 
elsewhere.  A  somewhat  similar  relation  exists  between  an  existing  syph- 
ilitic lesion  and  the  development  of  carcinoma.  Whether  actual  transforma- 
tion can  occur  or  not,  it  is  certain  that  cancer  may  develop  in  tissues  that 
.are  indubitably  affected  by  syphilis,  and  that  the  cancer  may  go  on  to  de- 
struction of  tissue  and  finally  prove  fatal.  This  may  occur  without  any 
Ijreliminary  change  in  the  physical  appearance  of  the  tissues  affected  by 
syphilis  prior  to  the  development  of  cancer.  The  author  feels  warranted  in 
speaking  thus  positively  from  experience  with  the  case  herewith  presented. 

In  regard  to  the  bacilhis  of  cancer,  it  is  as  yet  an  unknown  quantity. 
So  far  as  the  bacillus  of  syphilis  is  concerned,  no  one  has  thus  far  been  able 
to  positively  demonstrate  that  the  supposed  bacillus  of  syphilis  is  really  the 
specific  bacillus.  That  S3'philis  is  a  specific  disease  is  not  open  to  question; 
that  it  is  due  to  a  microbe  is  well-nigh  certain.  A  demonstration  of  this, 
however,  demands  the  fulfillment  of  all  the  conditions  imposed  by  Koch  in 
proving  the  bacillus  tuberculosis. 

To  put  the  matter  of  the  transformation  of  syphilis  into  cancer  con- 
cisely, the  author  does  not  believe  that  syphilitic  cells  can  possibly  be  trans- 
formed into  cancer-cells,  but  holds  that  the  irritation  of  the  tissues  pro- 
duced by  the  former  may,  in  the  presence  of  favorable  constitutional  and 
local  conditions,  develop  a  new  process  of  tissue-building  or  neoplastic  de- 
posit resulting  in  the  formation  of  cancer-cells. 

Case. — A  man,  29  years  of  age,  contracted  syphilis  at  the  age  of  18.  He  stated 
that  the  resulting  chancre  inflamed  and  caused  paraphimosis,  which  lasted  about  a 
month  and  left  the  mucous  membrane  of  the  penis  in  an  irritable  condition  that 
resulted  in  the  frequent  appearance  of  fissures  and  ulcerations — some  of  which  de- 
veloped from  time  to  time  after  he  came  under  the  author's  care.  Secondary  symptoms 
appeared  about  four  months  after  the  initial  lesion,  and,  according  to  the  description, 
a  pronounced  papulo-pustular  eruption  appeared  and  resulted  in  considerable  scarring 
of  the  skin.  Mucous  patches  presented  themselves  in  successive  groups  and  were 
very  annoying,  especially  those  upon  the  tongue.  After  the  secondary  period  became 
manifest  his  physician  put  him  upon  mercury,  a  thorough  course  being  given  for 
about  three  months,  after  which  he  went  to  the  Hot  Springs.  He  remained  at  the 
springs  for  three  months,  was  rubbed  with  an  enormous  amount  of  mercury,  and 
badly  salivated  twice.  He  went  home  and  at  the  end  of  two  months  eruptions  again 
appeared  upon  the  body  with  larger  mucous  patches  than  before,  his  tongue  at  this 
time  giving  considerable  trouble  from  general  soreness  of  the  organ.  At  this  time  an 
old  eczema  of  the  hands,  that  had  troubled  the  patient  off  and  on  all  his  life, 
developed,  and  in  combination  with  the  syphilis  gave  him  a  great  deal  of  trouble.  He 
again  went  to  the  springs  and  remained  there  for  eleven  weeks,  during  which  time 
he  took  mercury  internally  quite  freely.  He  returned  home  and  was  apparently  well 
for  three  months,  when  mucous  patches  and  eruptions  appeared,  sores  appearing  at 
this  time  upon  the  penis.  About  five  years  after  the  beginning  of  the  syphilis  the 
patient  fell  under  the  care  of  a  physician  who  again  rubbed  him  freely  with  mercury, 


TEAXSFOKilATIOX    OF    SYPHILIS    IXTO    CAXCEE.  443 

the  treatment  being  continued  for  about  six  months.  He  improved  for  a  time  and 
then  quit  treatment,  as  such  patients  frequently  do,  but,  growing  worse,  went  back 
to  the  same  physician,  and  for  at  least  eighteen  months  took  mercury  in  consider- 
able quantity.  He  was  then  advised  to  go  to  Mount  Clemens,  Michigan;  he  remained 
there  about  fifteen  months,  and  while  there  became  entirely  well  of  his  eczema,  the 
syphilis,  however,  never  leaving  him  entirely. 

In  1884  the  patient  consulted  the  author  for  the  first  time.  He  had  then  un- 
equivocal cerebral  syphilis,  and  tuberculo-squamous  syphilides  in  considerable  number 
were  scattered  about  the  forehead,  forearms,  and  thighs,  with  a  few  scattered 
squamas  upon  the  trunk.  Scars  of  former  pustular  syphilides  were  visible  upon 
the  forehead,  forearms,  and  legs;  the  tibias  and  sternum  were  excessively  tender,  and 
considerable  pain  was  experienced  at  night.  Cephalalgia  was  a  constant  symptom  and 
gave  the  patient  intense  suffering.  An  apparently  gummy  ulceration  with  several 
fissures  existed  upon  the  penis  just  back  of  the  corona. 

The  tongue  was  rough,  and  coated  with  a  thick,  dirty,  yellowish-gray  fur,  with 
marked  dryness  in  the  center  and  posterior  part  of  the  organ.  Several  tubercular 
nodules  were  also  observable,  one  in  the  center  of  the  tongue  and  the  others  near  its 
base,  those  upon  the  right  side  being  especially  marked.  On  inquiry  it  developed 
that  the  tobacco  and  alcohol  habits  had  been  persisted  in  for  a  greater  portion  of 
the  time  that  he  had  been  under  treatment,  and,  strange  to  say,  he  stated  that  his 
23hysicians  had  not  restricted  him  in  the  matter  of  either  indulgence.  The  treatment 
at  this  time  Avas  very  vigorous;  codliver-oil  and  iron  were  ordered  on  account  of 
the  patient's  marked  debility.  The  mixed  treatment  and  potassic  iodid  in  saturated 
solution  were  given,  the  iodid  being  run  rapidly  up  to  a  dose  of  300  grains  per  diem, 
and  maintained  at  that  point  for  three  weeks,  the  disease  being  completely  resistant 
to  treatment  until  the  end  of  that  time.  Local  applications  of  acid  nitrate  of  mercury 
were  made  to  the  tongue  from  time  to  time,  with  apparent  benefit.  As  soon  as  the 
symptoms  began  to  yield  to  treatment  the  dose  of  the  iodid  was  diminished  to  about 
60  grains  per  day,  the  tonics  being  meanwhile  continued.  At  the  end  of  three 
months  the  patient  was  free  from  trouble,  with  the  exception  that  his  tongue  was 
more  thickly  coated  than  ever  (psoriatic),  and  the  nodules  upon  its  surface  were  still 
perceptible.  No  amount  of  care  and  treatment  ever  caused  this  condition  of  the 
tongue  to  Qisappear  entirely,  and  as  the  history  will  show,  it  subsequently  became 
the  source  of  terrible  trouble.  The  case  remained  comparatively  well  for  some 
months,  the  tongue  creating  some  uneasiness  from  time  to  time  on  account  of  com- 
mencing ulceration  of  the  nodules  upon  its  surface,  but  yielding  rapidly  to  treatment. 
On  each  occasion,  however,  the  nodules  and  furring  of  the  tongue  became  more  promi- 
nent, and  remained  so  in  spite  of  treatment,  the  furring  becoming  a  sort  of  mem- 
branous deposit  like  wet  chamois-leather,  that  reformed  as  fast  as  it  was  removed. 

At  this  time  while  at  the  Hot  Springs  under  the  care  of  Dr.  S.  S.  Vaughn,  the 
tongue  began  to  swell,  and  assumed  a  threatening  appearance;  the  nodules  began 
to  ulcerate,  and  at  one  time  a  severe  hemorrhage  occurred. 

After  all  means  of  treatment  had  been  tried  for  two  months  without  avail  the 
case  was  pronounced  probably  cancerous  by  the  attending  physician  and  several 
others  who  saw  it  in  consultation.  At  this  time  Dr.  Vaughn  refen-ed  the  case  to  the 
author  with  a  view  to  possible  excision.  Upon  examination  the  tongue  was  found 
filling  the  mouth  and  pressing  upon  the  teeth  in  such  a  manner  that  it  had  become 
eroded  and  ulcerated  by  them.  Salivation  was  profuse;  a  deep  ulcer  existed  at  the 
center  and  back  part  of  the  organ ;  the  enlargement  seeming  to  be  rather  more  marked 
upon  the  right  side.    There  were  no  other  lesions  present  upon  any  part  of  the  body. 

Microscopic  examination  at  this  time  failed  to  demonstrate  the  presence  of 
cancer.  No  further  examination  of  the  tissues  was  made  until  after  the  tongue  had 
been  excised. 


444  PEEIOD    OF    SEQUELS. 

As  the  patient  experienced  great  difficulty  in  masticating  and  swallowing,  he 
was  subsisting  entirely  upon  fluid  food,  and  not  being  very  robust  primarily  had 
become  greatly  emaciated.  The  treatment  instituted  was  chiefly  a  tonic  one,  in  con- 
junction with  an  alterative  mixture  containing  sodic  iodid  and  the  chlorid  of  gold; 
milk-punches  were  allowed  and  the  patient  instructed  to  take  as  much  sweet  cream 
and  milk  as  he  could  without  creating  digestive  disturbance.  Local  applications 
were  made  of  a  compound  of  carbolic  acid.,  iodin,  and  menthol  in  mild  strength. 
Improvement  was  at  first  very  rapid,  and  at  the  end  of  a  week  the  tongue  was  nearly 
reduced  to  its  normal  size.  In  a  few  days,  however,  it  again  enlarged  upon  the  right 
side,  this  enlargement  being  peculiar  in  that  it  was  limited  by  the  raphe,  the 
tongue  being  at  least  double  the  thickness  upon  the  right  side  that  it  was  upon  the 
left.  The  appearance  was  precisely  the  same  as  that  presented  by  certain  cases  of 
acute  glossitis,  a  condition  that  it  strongly  resembled  in  the  rapidity  of  its  appear- 
ance, the  increased  thickening  having  come  on  within  twenty-four  hours.  This 
condition  of  the  right  side  of  the  tongue  soon  subsided,  but  was  succeeded  by 
enlargement  of  the  tubercular  nodules  previously  mentioned  and  by  the  appearance  of 
several  new  nodules.  These  appeared,  not  upon  the  margin  of  the  tongue,  but  upon  its 
upper  surface.  Within  a  few  days  the  left  side  of  the  tongue  underwent  a  diiTuse 
enlargement,  similar  to  that  which  had  occurred  upon  the  right,  and  in  the  same  way 
subsided  and  was  succeeded  by  the  development  of  tubercular  nodules.  The  whole 
tongue  now  gradually  increased  in  volume  and  became  so  large  that  it  hung  over  the 
edges  of  the  teeth  and  protruded  through  spaces  left  by  extracted  teeth.  There  was 
little  or  no  pain,  and  such  as  there  was  was  referred  by  the  patient  to  the  "holes," 
as  he  expressed  it,  worn  in  the  tongue  by  the  teeth. 

The  case  went  on  from  bad  to  worse,  many  different  plans  of  treatment  being 
tried  without  avail.  The  sloughing  continued  until  the  tongue  was  in  such  con- 
dition that  even  if  healing  had  been  possible  the  organ  would  have  been  practically 
useless.  The  base  of  the  tongue  was  a  foul  mass  of  hyperplastic  ulcerating  tissue,  the 
odor  and  secretion  from  which  were  not  only  offensive  to  the  patient,  but  prominent 
factors  in  producing  the  constitutional  disturbance.  There  seemed  to  be  no  hope  of 
benefit  from  either  internal  or  local  medication,  and  in  addition  the  malignancy  of 
the  process  appeared  to  be  now  clinically  established,  although  microscopic  evidence 
was  by  no  means  satisfactory.  As  the  patient  was  anxious  to  have  something  done 
to  remove  the  foul  and  stinking  mass  from  his  mouth,  excision  with  the  galvano- 
cautery  was  proposed:  an  operation  to  which  the  patient  readily  consented.  At  the 
end  of  a  Aveek  the  eschar  produced  by  the  caviterization  became  detached  and  left 
a  surface  of  fairly  healthy  appearance;  the  fetor  of  the  breath  was  gone  and  the 
sloughing  at  the  base  of  the  tongue  had  ceased.  The  floor  of  the  mouth  healed  nicely 
and  remained  in  a  tolerably  healthy  condition  for  several  weeks.  The  general  con- 
dition of  the  patient  improved  considerably.  About  a  month  after  the  operation, 
however,  the  submaxillary  glands  became  enlarged  and  quite  tender.  There  was 
comparatively  little  pain  save  a  moderate  amount  of  cephalalgia  and  otalgia.  The 
ulcerative  process  on  the  floor  of  the  mouth  recurred,  but  did  not  progi'ess  rapidly 
nor  ulcerate  extensively.  A  small  ulcer  formed  upon  the  right  pillar  of  the  fauces. 
These  symptoms  practically  settled  the  question  of  malignancy.  Dr.  I.  X.  Danforth 
having  examined  the  specimens  excised  informed  me  at  this  time  that  the  case 
was  of  a  sarcomatous  character,  but  from  his  report  it  would  be  inferred  that  it 
did  not  present  typic  characters.  About  two  months  after  the  operation  an  abscess 
formed  in  the  submaxillary  glands.  This,  when  opened,  gave  exit  to  a  thin,  sanious 
fluid.  Pain  at  this  time  was  very  severe.  At  the  end  of  about  three  months  an 
occasional  slight  hemorrhage  from  the  mouth  occurred.  The  patient  finally  died 
about  four  months  after  the  operation  from  a  sudden  hemorrhage  occurring  during 
the  night. 


SEQUELAE    LESIONS    OF    THE    MOUTH    AND    TONGUE.  445 

This  imfortimate  case  is  in  many  respects  unlike  any  others  on  record. 
The  literature  of  the  subject  is  very  meager.  During  the  course  of  the  dis- 
ease there  were  present  distinctive  features  of  several  forms  of  glossal  affec- 
tion. During  the  four  years  that  the  patient  was  under  observation,  the 
tongue  presented  gummy  nodules  and  ulceration,  lingual  psoriasis,  diffuse 
syphilomatous  deposit,  and  latterly  attacks  of  subacute  glossitis.  At  various 
times  before  coming  under  observation,  and  once  afterward,  as  shown  by  the 
history,  mercurial  stomatitis  occurred  and  formed  an  important  feature  of 
the  case,  particularly  as  regards  the  etiology  of  the  process  that  finally 
necessitated  removal  of  the  tongue.  Prior  to  extensive  destruction  of  the 
organ  these  various  conditions  merged  into  a  general  hypertrophy,  the 
tongue  becoming  extremely  indurated.  These  various  features  must  be 
taken  into  consideration  in  studying  the  case. 

Macroglossia,  or  hypertrophy  of  the  tongue,  of  a  simple  character  is 
very  rarely  seen;  a  few  cases  of  congenital  origin  are  on  record.  x4.ccording 
to  Fairlie  Clark,^  hypertrophy  of  the  tongue  occurring  later  in  life  may  arise 
"spontaneously"  (?),  or  from  wounds,  mercurial  salivation,  or  as  a  conse- 
quence of  diffuse  inflammation  from  scarlet  and  other  forms  of  fever.  The 
author  will  add  to  these  causes  constitutional  syphilis. 

Attrition  against  the  teeth  in  these  cases  of  macroglossia  produces  from 
time  to  time  attacks  of  acute  or  subacute  glossitis,  each  of  which  leaves  the 
tongue  more  enlarged  than  before.-  This  was  a  prominent  feature  of  the 
case  at  present  under  consideration. 

The  continued  use  of  alcohol  and  tobacco  in  combination  with  the 
irritation  produced  by  diseased  teeth  completed  a  chain  of  circumstances 
which,  in  combination  with  the  syphilitic  cachexia,  favored  the  development 
of  the  malignant  process  in  the  tongue. 

Sequelae  Lesions  or  the  Mouth  and  Tongue. — Lesions  of  the 
mucous  membranes  in  early  syphilis  are  so  characteristic  and  so  intimately 
related  to  the  active  period  of  the  disease  that  even  general  practitioners 
are  more  or  less  familiar  with  their  pathologic  characters  and  treatment. 
The  sequelar,  or  so-called  tertiary,  mucous  lesions  are,  however,  not  well 
understood,  despite  the  fact  that  they  are  of  far  greater  importance,  inas- 
much as  the  earlier  lesions  have  -an  intrinsic  tendency  to  recover,  other 
things  being  equal,  while  those  of  a  later  period  are  characterized  by  extreme 
chronicity  and  a  stubborn  tendency  to  recurrence. 

Certain  lesions  of  the  mucous  membranes  late  in  the  history  of  syph- 
ilitics  are  the  most  typically  sequelar  of  all  the  late  lesions  of  the  disease, 
inasmuch  as  they  are  the  result,  not  only  of  syphilis  per  se,  but  of  numerous 
other  factors  to  which  the  mucous  membranes  are  exposed  during  the  active 
period  of  the  disease  or  during  the  intermissions  between  the  active  mani- 


"Diseases  of  the  Tongue." 
'  Koenig,  "Lehrbuch  der  specielen  Chirurgie,"  1878. 


446  PERIOD    OF    SEQUELS. 

festations.  The  jaost-syphilitic  character  of  the  lesions  in  many  instances  is 
so  marked  that  ordinary  antisyphilitic  treatment  either  has  no  effect  what- 
ever or  is  injurious.  These  lesions  occur  in  the  form  of  hyperplastic  infil- 
trations of  greater  or  less  extent  of  the  mucous  and  submucous  tissues. 
These  have  been  classed  by  different  authorities  as  leucoplakia^  by  others  as 
leucoplasia — terms  that  are  intended  to  convey  the  characteristic  whitish 
appearance  of  many  of  them  and  their  tendency  to  arrange  themselves  in 
distinct  hyperplastic  plaques.  The  term  post-syphilitic  leucoplasia  is  prob- 
ably as  comprehensive  and  accurate  as  any  that  have  thus  far  been  sug- 
gested. The  terms  psoriasis,  ichthyosis,  tylosis,  leucokeratosis,  diskeratosis, 
and  hyperkeratosis  serve  simply  to  add  confusion  to  the  subject. 
Perrin  believes  that: — 

1.  The  white  hyperplastic  plaques,  presenting  themselves  as  syphilitic  or  post- 
syphilitic phenomena,  have  for  their  elementary  characters  functional  and  organic 
disturbances  of  the  epithelium.  2.  They  may  occur  as  a  consequence  both  of  the 
syphilis  and  antisyphilitic  treatment.  3.  In  some  instances  there  exists  some  peculiar 
morbid  constitutional  condition  or  diathesis  as  the  predisposing  cause  of  leucoplasia. 
4.  Such  conditions  are  peculiarly  liable  to  occur  in  both  syphilitic  and  non-syphilitic 
patients  Avho  are  addicted  to  tobacco.  5.  There  is  a  large  number  of  cases  of  mixed 
character  in  which  the  condition  is  excited  by  syphilis  and  tobacco  combined  in 
gouty  or  rheumatic  subjects. 

It  may  be  doubted  whether  leucoplasia  should  be  classified  as  a  distinct 
pathologic  entity,  but  most  of  those  who  have  studied  such  cases  will  hardly 
question  the  assertion  that  these  lesions  present  traits  that  are  sufficiently 
characteristic  to  warrant  such  classification.  From  a  clinical  stand-point 
there  can  be  no  question  of  its  accuracy. 

With  reference  to  the  relation  of  syphilis  to  leucoplasia,  however,  the 
occurrence  of  the  latter  independently  of  the  former  must  be  taken  into 
consideration;  indeed,  when  we  consider  the  large  proportion  of  patients 
who  indulge  in  tobacco  and  liquor,  with  or  without  overactive  mercurial 
therapeusis,  it  is  rational  to  infer  that,  even  in  cases  in  which  syphilis 
appears  to  be  primarily  responsible  for  leucoplasia,  the  affected  individual 
must  be  possessed  of  some  peculiar  predisposition  that  differentiates  him 
from  the  average  syphilitic.  In  several  instances  the  author's  attention  has 
been  directed  to  the  question  of  idiosyncrasy  as  an  explanation  for  the  oc- 
currence of  leucoplasia  by  the  occurrence  of  such  lesions  in  syphilitic  blood- 
relations. 

Post-syphilitic  leucoplasia  derives  its  chief  importance  from  the  fact 
that,  while  its  dependence  upon  syphilis  is  usually  recognized,  the  mistake 
is  made  of  believing  that  the  lesions  should  be  quite  as  tractable  under  anti- 
syphilitic treatment  as  other  lesions  of  the  mucous  membranes  occurring  in 
this  disease.  As  a  matter  of  fact,  these  lesions  must  be  regarded  essentially 
as  non-syphilitic  neoplasms  occurring  upon  a  syphilitic  foundation.  With 
this  in  mind  the  practitioner  may  perhaps  readily  comprehend  the  correct 


POST-SYPHILITIC    LEUCOPLASIA.  447 

principles  of  treatment.  Forgetting  this^  he  is  likely  to  do  the  patient  in- 
calculable injury  through  misguided  and  enthusiastic  efforts  to  cure  the 
lesions  by  strictly  antisyphilitic  treatment.  Ordinary  local  treatment  simply 
aggravates  the  difficulty,  as  a  rule,  and  only  the  most  radical  measures  are 
likely  to  be  effective. 

A  further  reason  for  regarding  these  lesions  as  important,  per  se,  is  the 
indubitable  fact  that  they  may  assume  a  malignant  character. 

The  condition  known  as  ichthyosis,  or  psoriasis,  of  the  tongue,  more 
properly  termed  leucoplasia,  is  due  to  the  same  causes  as  generalized  glossitis, 
and  is  really  a  similar  process  in  which  the  inflammation  is  localized  upon 
the  surface  of  the  mucous  membrane. 

According  to  Hulke,  ichthyosis— i.e.,  leucoplasia — of  the  tongue  con- 
sists essentially  in  hypertrophy  of  the  epithelial  and  papillary  elements  of 
the  mucous  membrane.^  The  relation  of  this  condition  of  the  tongue  to 
syphilis  and  cancer  is  very  important.  All  authorities  unite  in  acknowledg- 
ing its  relations  to  syphilis, — although  it  may  occur  in  non-syphilitics.  In 
appearance  it  resembles  in  some  cases  a  deposition  of  wet  chamois-leather 
upon  the  surface  of  the  tongue  which  rapidly  reforms  after  removal.  In 
other  instances  it  resembles  a  thin  layer  or  film  of  coagulated  albumin,  and 
in  these  cases  each  successive  deposit  is  more  dense  and  adherent  than  the 
preceding.  That  the  condition  is  prone  to  develop  epithelial  cancer  Weir 
has  shown  most  conclusively  by  the  history  of  68  cases,  of  w^hich  number  35 
eventually  developed  epithelioma.^ 

Hutchinson  has  also  advanced  the  opinion  that  cases  of  syphilitic  dis- 
ease of  the  tongue  are  especially  prone  to  develop  epithelioma  later  in  life. 

The  condition  underlying  leucoplasia  does  not  always  develop  distinct 
white  plaques  of  hyperplastic  epithelium.  Some  local  perversion  of  nutri- 
tion may  develop  fissures  of  greater  or  less  depth  and  extent,  with  margins 
of  hyperplasic  epithelium,  or  the  edges  of  which  may  have  become  trans- 
formed by  atrophy,  presenting  a  smooth,  glazed,  and  dry  appearance,  the 
characteristic  papillated  appearance  of  the  tongue  being  replaced  by  a 
smooth,  quasimucous  surface.  In  other  instances  distinct  ridges  of  greater 
or  less  extent  present  themselves,  particularly  along  the  tongue  or  the 
inner  surface  of  the  buccal  mucous  membrane  at  the  point  of  contact  of 
the  tongue  and  cheek  with  the  teeth.  This  form  of  epithelial  hyperplasia 
is  particularly  apt  to  occur  in  patients  who  have  been  overtreated  with 
mercury.  We  find  in  other  instances  the  classic  type  of  leucoplasic  forma- 
tion in  which  more  or  less  elevated,  distinct,  whitish  plaques  of  epithelial 
overgrowth  are  noted.  These  plaques  may  undergo  transformation,  and  pre- 
sent the  smooth,  reddened,  glazed  appearance  already  described  in  connec- 
tion with  fissures.    The  cases  in  which  the  epithelium  is  transformed  in  this 


^  "Clinical  Society  Reports,"  vol.  ii,  p.  1. 

^  New  York  Medical  Journal,  March  18,  1875. 


448  PEEIOD    OF    SEQUELS. 

manner  are  characterized  by  extreme  irritability,  lesions  that  are  trivial  in 
appearance  giving  rise  to  considerable  irritation  and  pain.  Excessive  smok- 
ers are  particularly  apt  to  present  lesions  of  this  character.  The  more  for- 
midable variety  of  post-syphilitic  neoplasm  occurs  in  the  form  of  distinct, 
circumscribed  nodules  of  greater  or  less  extent  that  have  a  tendency  to  de- 
velop along  the  margins  of  the  tongue,  but  are  often  seen  upon  one  or  the 
other  side  of  the  lingual  raphe,  and  in  some  instances  limit  themselves  en- 
tirely to  the  base  of  the  tongue  upon  one  or  both  sides.  These  lesions  are 
very  apt  to' be  mistaken  for  gummata.  Doubtless  nodular  gummy  infiltra- 
tion is  the  point  of  departure  for  the  lesion  in  some  instances,  but  instead  of 
resolution,  suppuration,  or  necrosis  occurring,  the  gummy  deposit  is  ap- 
parently removed  or  transformed — at  least,  it  is  replaced  by  a  distinct  con- 
nective-tissue new  growth.  This  may  subside  to  a  certain  extent,  but  is  very 
likely  to  remain  permanently  and  enlarge  from  time  to  time,  each  successive 
exacerbation  being  followed  by  an  increase  of  permanent  enlargement.  Such 
nodules  are  to  be  regarded  as  extremely  dangerous,  as  it  is  this  form  of  post- 
syphilitic mucous  lesions  that  is  most  likely  to  undergo  malignant  trans- 
formation. The  lesions  above  described  have  long  been  regarded  by  the 
author  as  evidence  in  favor  of  the  theory  that  post-syphilitic  phenomena  are 
largely  trophoneurotic.  Trophoneurotic  disturbances  of  a  permanent  char- 
acter associated  with  various  causes,  such  as  local  irritation  affecting  the 
mucous  membrane,  etc.,  should  be  all-sufficient  to  explain  the  peculiarities 
of  the  lesions  under  consideration. 

Even  a  superficial  study  of  these  lesions  should  convince  the  practical 
clinician  that  it  is  but  a  step  between  these  benign  overgrowths  of  epithe- 
lial and  connective  tissue  and  malignant  neoplasm.  The  author  regards  the 
nodular  variety  of  the  affection  as  essentially  precancerous.  In  this  view 
alone  lies  the  safety  of  the  patient. 

In  the  treatment  of  leucoplasia  of  the  mucous  membranes  several  fac- 
tors must  be  taken  into  consideration,  viz.: — 

1.  The  possible  existence  of  a  certain  degree  of  activity  of  the  original 
constitutional  trouble — syphilis. 

2.  The  question  whether  syphilis  per  se  has  not  long  since  been  eradi- 
cated, as  a  consequence  of  which  antisyphilitic  treatment  will  simply  add 
fuel  to  the  fire. 

3.  The  relation  of  previous  antisyphilitic  treatment — particularly  in 
the  direction  of  overdosing  with  mercury — to  the  lesions  present. 

4.  The  existence  of  trophoneurosis,  as  a  result  of  syphilis,  treatment, 
or  most  probably  of  idiosyncrasy. 

5.  The  relation  of  local  irritants,  such  as  tobacco,  liquor,  highly-sea- 
soned food,  and  the  application  of  caustics. 

6.  And  most  important  of  all,  the  circumstance  that  the  lesion  may  re- 
quire attention  as  a  neoplastic  entity  independently  of  its  relation  to  any  of 


SYPHILIS    OF    SPECIAL    STEUCTUEES.  449 

the  foregoing  factors^  with  the  distinct  object  in  mind  of  preventing  trans- 
formation into  malignant  disease. 

Effect  of  Syphilis  upox  Special  Stehctuees. — At  this  juncture  it 
may  be  profitable  to  review  briefly  the  more  important  effects  of  syphilis 
upon  some  of  the  special  structures  of  the  body. 

Mucous  Membranes. — The  initial  sclerosis  may  or  may  not  be  situated 
upon  a  mucous  surface.  Following  the  primary  sore,  mucous  jJatches  appear 
upon  the  mucous  or  quasimucous  surfaces,  the  circumstances  favoring  their 
development  being  (1)  heat,  (2)  moisture,  (3)  local  irritation,  and  (4)  filth. 
They  consist  of  slightly-elevated  grayish  plaques,  presenting  something  of 
the  appearance  of  a  superficial  diphtheritic  deposit.  The}^  may  vary  in  size 
from  the  dimensions  of  a  split  pea  to  a  penny.  Occasionally — especially 
about  the  anus,  scrotum,  and  female  genitals — they  undergo  hypertrophy 


Fig.  116. — Dactylitis  syphilitica.     (After  Berg.) 

or  hyperplasia,  forming  mucous  tubercles  or  condylomata.  The  mucous 
patch  is  most  often  seen  in  the  mouth.  Its  development  is  favored  by  the 
irritation  produced  by  the  food,  carious  teeth,  and,  above  all,  by  tobacco. 
It  may  undergo  ulceration.  Diffuse  congestion  or  hyperemia  of  the  faucial 
mucous  membrane  is  a  feature  of  secondary  syphilis.  The  vocal  apparatus 
may  be  involved,  causing  hoarseness  or  even  aphonia.  Gummy  ulceration 
of  the  mucous  membranes  may  occur  in  late  syphilis. 

SMn. — The  lesions  of  the  skin  are  those  that  have  been  already  de- 
scribed as  the  syphilides  or  syphilodermata.  These  embrace  almost  every 
known  form  of  skin  eruption  and  are  hence  designated  as  polymorphous. 
Thus,  syphilis  may  present  every  variety  of  skin-lesion  from  a  simple  macular 
efflorescence  to  extensive  ulceration.  Ecthyma  is  a  late  eruption  of  large 
pustules  followed  by  small  circular  ulcers  covered  with  greenish  crusts. 


450 


PERIOD    OF    SEQUELS. 


Eupia  consists  of  larger  ulcerations  covered  by  imbricated  crusts  resem- 
bling an  03'Ster-sliell.  These  eruptions  have  already  been  described  in  detail. 
The  Hair  and  Nails.  —  The  epithelial  appendages  of  the  skin  are 
peculiarly  susceptible  to  derangements  of  nutrition  in  syphilis.  Alopecia 
syphilitica  and  onychia  have  already  been  expatiated  upon.  A  brittle  con- 
dition of  both  nails  and  hair  is  a  frequent  concomitant,  or,  more  especially, 
a  sequel  of  syphilis.  Dryness  of  the  scalp  with  a  dry,  brittle  condition  of 
the  hair  is  often  seen  after  the  syphilis  proper  is  apparently  cured.  The 
hair  becomes  more  or  less  thinned,  but  does  not  shed  in  the  characteristic 
areate  form  of  the  earlier  period.  Sometimes  all  of  the  hair  is  shed  from 
the  entire  bodv. 


Fig.  117. — Dactylitis  syphilitica  with  absorption  of  boue. 
(After  McCready.) 


The  Fingers  and  Toes. — The  digits  are  occasionally  the  seat  of  a  pecul- 
iar spindle-shaped  enlargement, — syphilitic  dactjditis, — due  to  thickening 
of  the  bones  and  periosteum  of  the  phalanges  from  cell-deposit.  Caries  or 
necrosis  occasionally  ocurs.  Absorption  of  the  affected  bone  ^yithout  caries 
sometimes  occurs. 

Syphilis  of  Connective  Tissue. — Whether  subcutaneous  or  in  the  vis- 
cera, syphilis  of  connective  tissue  presents  itself  as  gummy  infiltration, 
diffuse  or  circumscribed.  Its  results  depend  on  the  structure  and  functional 
importance  of  the  tissue  or  organ  involved. 

Male  Sexual  Organs. — Besides  the  chancre  and  the  mucous  patch, 
there  may  develop  in  this  locality  flat  condylomata  and,  in  the  late  secondary 


SYPHILIS    OF    SPECIAL    STEUCTUEES.  451 

or  tertiary  period,  severe  and  destructive  gummy  ulceration.  Chronic  infil- 
tration of  the  corpora  cavernosa  may  develop.  The  urethra  may  be  the  seat 
of  patches,  ulcers,  or  condylomata. 

The  testes  may  be  affected  in  one  of  two  ways,  viz.:  by  diffuse  syph- 
ilomatous  deposit,  or  by  circumscribed  syphiloma  or  gumma.  The  diffuse 
form  gives  rise  to  the  painless  enlargement  fallaciously  termed  syphilitic 
sarcocele,  or,  more  inaccurately  still,  "syphilitic  orchitis."  The  gummy  de- 
posit may  resolve  or  it  may  suppurate. 

Female  Sexual  Organs. — Chancre  may  occur  on  the  vulva,  vagina,  or 
cervix  uteri.  Mucous  patches  are  frequent  and  are  the  principal  factors 
in  transmitting  the  disease.  Condylomata  are  especially  apt  to  develop  in 
women.  Destructive  gummy  ulceration  may  cause  atresia  of  the  vagina  in 
late  syphilis. 

Anus. — The  anus  may  be  the  seat  of  mucous  patches,  huge  condylo- 
mata, ulceration,  and  fissure,  and  sometimes  the  primary  sore. 

Oro-pharynx. — The  mouth,  gums,  lips,  or  tongue  may  be  the  seat  of 
the  primary  sore,  and,  later  on,  of  patches,  ulcers,  or  gumma.  Chancre  of 
the  tonsil,  while  rare,  is  sufficiently  frequent  to  demand  attention.  Leuco- 
plasia  of  the  mouth  and  tongue  has  been  exhaustively  discussed. 

Nose. — In  the  earlier  stages  a  catarrhal  discharge,  with  or  without 
mucous  patches,  may  occur.  Later  on,  ulceration  and  necrosis  with  offensive 
discharge — ozena — may  occur  and  the  bones  may  be  destroyed,  with  conse- 
quent flattening  of  the  organ. 

Larynx. — The  larynx  may  be  affected  early  by  diffuse  congestions; 
later  on,  by  ulcerations  that  may  impair  the  structure  and  function  of  the 
vocal  cords.     Complete  aphonia  may  occur. 

JEyes. — Iritis  from  early  cell-deposit  and  later  from  gummy  infiltration 
of  the  iris  may  occur.  Circumscribed  gummy  deposit  and  resulting  hypo- 
pyon or  pus  in  the  anterior  chamber  may  be  observed.  Choroiditis  and 
retinitis  are  occasionally  seen.  The  retina  may  be  involved  in  diffuse  in- 
filtration. 

Bones. — The  bones  and  periosteum  are  often  affected  by  cell-deposit, 
with  resulting  severe  pain  in  the  secondary  stage.  In  the  late  secondary 
and  tertiary  periods,  bone-swellings,  termed  nodes,  subperiosteal  suppura- 
tion, and  caries  or  necrosis  may  be  seen.  These  changes  are  most  often  seen 
in  exposed  and  flat  bones:  e.g.,  the  tibias,  sternum,  cranial  bones,  and 
clavicles. 

Liver,  Spleen,  and  Kidneys. — These  organs  are  often  the  seat  of  dif- 
fuse or  circumscribed  syphiloma.  In  the  diffuse  form  organization  and 
contraction — cirrhosis — of  the  new  tissue  may  result.  Amyloid  degenera- 
tion of  these  organs  is  usually  associated  with  necrosis  of  bone  in  late 
syphilis. 

Cerebrospinal  Axis  and  Nerves. — The  brain  and  cord  may  be  the 
seat  of  diffuse  or  circumscribed  gummy  deposits.     When  situated  in  the 


452 


PEBIOD    OF    SEQUELS. 


brain,  the  results  may  be  pain,  sleeplessness,  disturbed  intellect,  paralysis, 
aphasia,  epilepsy,  coma,  and  death.  The  cerebral  vessels  may  be  occluded 
or  atheromatous,  causing  apoplexy  or  softening.  Gummy  deposit  in  the 
cord  gives  rise  to  nervous  disturbance  depending  upon  the  portion  of  the 
cord  affected:  e.g.,  in  the  cervical  region,  respiratory  paralysis  and  death 
may  ensue,  while  in  the  lower  portion  of  the  cord  paraplegia  and  paralysis 
of  the  bladder  and  sphincter  ani  may  result.  Neuroma,  meningitis,  and 
neuritis  are  sometimes  observed.  Nervous  symptoms  due  to  syphilitic  toxins 
may  occur,  especially  in  early  syphilis. 

Synopsis  of  a  Typic  Case  of  Syphilis. — It  may  be  serviceable  to 
the  student  to  present  a  brief  synopsis  of  the  course  of  a  typic  case  of 


Fig.  118. — Showing  cranial  hyperostoses  from  tertiary  syphilis.  Exostosis  in 
right  orbit  shows  clearly.  The  ramus  of  the  right  side  of  the  inferior 
maxilla  shows  syphilitic  necrosis.  Note  the  overgrowth  and  destruction 
of  bone  associated  in  the  same  subject.  This  skull  is  very  dense  and 
heavy.     (Author's  specimen.) 

syphilis:  The  patient  has  exposed,  himself  to  infection  by  a  suspicious  'in- 
tercourse, and  during  the  performance  of  the  act  causes  a  little  abrasion 
upon  the  penis — or  possibly  he  still  farther  irritates  or  abrades  a  pre-ex- 
isting abrasion  or  patch  of  herpes.  This  abrasion  may  heal  in  a  day  or 
two — or  may  escape  his  attention  entirely,  for  that  matter — or  may  persist. 
In  about  two  or  three  weeks  a  little  hard  lump  or  nodule  appears  on  the 
site  of  the  abrasion.  This  gradually  enlarges  until  it  attains  the  size,  per- 
haps, of  a  filbert.     In  a  few  days — say  five  to  eight — small  lines  of  hard- 


SYPHILIS    OF    SPECIAL    STBUCTUKES. 


453 


ness  appear  beneath  the  integument  of  the  penis  leading  from  the  indura- 
tion^ and,  in  a  few  days  more,  small,  hard,  and  freely  movable  lumps  appear 
in  the  groins.  These  phenomena  constitute  primary  syphilitic  lymphopathy 
and  adenopathy.  There  is  now  an  interval  of  perhaps  six  weeks,  after  which 
an  enlargement  of  the  cubital  or  epitrochlear  glands  at  the  elbow  over  the 
internal  condyle  is  noted.  This  is  quite  characteristic,  and  is  succeeded  or 
attended  by  enlargement  of  the  general  sj^stem  of  lymphatics.  Within  two 
or  three  days — perhaps  at  the  same  time — an  eruption  of  erythematous  spots, 
macules  or  fine  papules  resembling  measles,  develops,  the  lesions  being  scat- 
tered over  the  surface  in  variable  amount.    This  eruption  may  appear  simul- 


Fig.  119. — Showing  osteoporosis  and  carious  destruction  of  frontal  region  from 
tertiary  syphilis.  Hyperostosis  at  site  of  irregular  prominence  above 
right  orbit.  This  skull  is  phenomenally  light  and  fragile.  (Author's 
specimen.) 


taneously  with  general  adenopathy  and  is  attended  by  a  still  further  increase 
in  the  size  of  the  lymphatic  glands.  Sore  throat  may  now  be  complained 
of.  A  varying  degree  of  toxemic  symptoms  may  occur  at  this  time — -head- 
ache, bone-pains  and  muscle-pains,  and  perhaps  fever. 

After  a  variable  interval  of  some  Aveeks  or  months  an  eruption  of 
prominent  papules  appears.  This  is  most  prominent  about  the  roots  of  the 
hair  on  the  forehead:  the  venereal  crown.  The  papules  may  become  vesic- 
ular or  pustular,  according  to  the  intensity  of  the  infection  and  the  con- 
stitutional condition  of  the  patient,  and  may  appear  before  the  roseola  has 


454  PEEIOD    OF    SEQUELS. 

gone.  Sore  throat  is  frequently  experienced  shortly  after  the  appearance 
of  the  roseola,  but  most  often  with  or  soon  after  the  papular  eruption. 

Iritis  is  likely  to  occur  at  any  time  after  the  appearance  of  the  papules. 
Late  in  the  disease  the  iritic  inflammation  takes  on  the  so-called  "gummy" 
or  nodular  form,  when  it  is  quite  characteristic,  but  the  early  syphilitic 
iritis  is  practically  indistinguishable  from  the  rheumatic  form. 

During  the  latter  part  of  the  first  year  bone-pains  and  nodes  are  apt 
to  develop;  but  they  may  appear  earlier.  Areate  falling  of  the  hair  occurs 
usually  during  the  early  months  if  at  all,  and,  in  common  with  the  form 
of  lesion  known  as  the  mucous  patch,  is  most  likely  to  develop  during  the 
papular  eruption.  General  shedding  of  the  hair  may  be  a  late  phenomenon. 
Dryness  and  brittleness  of  the  nails  are  apt  to  occur  as  late  secondary  or 
sequelar  lesions,  even  when  the  patient  has  otherwise  suffered  very  little  from 
his  disease.  Should  the  matrix  of  the  nail  become  infiltrated,  onychia  syph- 
ilitica is  likely  to  result  and  is  exceedingly  tedious. 

Pustular  and  ulcerative  lesions  begin  to  appear  during  the  latter  part 
of  the  first  year  or  eighteen  months,  and  are  succeeded  by  ecthyma,  rupia, 
and  tubercular  or  gummy  lesions  of  the  bones,  skin,  brain,  and  other  viscera. 

Various  nervous  lesions  may  crop  out  from  time  to  time  during  the 
patient's  future  existence.  They  may  be  delayed  until  very  late  in  life. 
Death  may  eventually  occur  from  profound  pathologic  changes  in  the  cere- 
bro-spinal  axis  or  abdominal  viscera.  As  illustrative  of  the  ravages  that 
a  severe  case  of  chronic  syphilis  and  its  sequels  are  capable  of  producing,  a 
case  under  the  author's  care  at  the  iSTew  York  Charity  Hospital  cannot  be 
excelled. 

Case. — A  Mexican,  40  years  of  age,  had  contracted  syphilis  five  years  before,  and 
at  the  time  he  entered  the  hospital  was  in  as  deplorable  a  condition  as  could  be 
imagined.  He  was  lame  from  osseous  complications,  and  had  but  one  arm,  the  other 
having  been  amputated  for  syphilitic  necrosis.  His  bodj'  was  covered  with  cicatrices 
from  former  ulcerative  syphilides,  and  his  hair  had  nearly  all  fallen  out  several  years 
before.  There  was  double  suppurative  inflammation  of  the  middle  ear,  and  secondary 
to  that  upon  the  right  side  was  a  large  abscess  beneath  the  scalp  posterior  to  the 
auricle,  from  which  was  evacuated  at  least  eight  ounces  of  as  foul-smelling  pus  as  ever 
saluted  a  surgeon's  nostrils.  The  tongue  was  shortened  and  bound  down  to  the 
floor  of  the  mouth  by  adhesions  from  old  ulcerations,  and  there  was  a  large  cavity 
in  the  superior  wall  of  the  pharynx  that  had  been  produced  by  ulceration,  but 
which  had  cicatrized.  The  epiglottis  had  been  destroyed,  and  a  small  circular  open- 
ing represented  the  glottis.  The  jaw  was  partially  ankylosed  from  old  inflammation 
of  the  articulations.  To  crown  all,  the  patient's  vision  was  impaired  from  old  iritic 
adhesions.  The  facetious  diagnosis  given  by  one  of  the  hospital  staff,  "shattered," 
quite  aptly  expressed  the  poor  patient's  condition.  Happily  for  him,  meningitis  super- 
vened in  a  few  weeks  and  ended  his  miserv. 


CHAPTEE  XIX. 

CONGEXITAL    SyPHILIS — ACQUIEED    StPHILIS    IX    ChILDEEN. 

Although  not  entirely  neglected  by  the  more  systematic  works  upon 
syphilis,  the  subject  of  congenital  and  infantile  syphilis  is  not  usually  pre- 
sented in  a  practical  and  sufficiently  comprehensive  manner.  Congenital 
syphilis  should  be  differentiated  from  infantile  syphilis  in  general,  for  the 
reason  that  children  may  acquire  the  disease  in  a  number  of  ways  inde- 
pendently of  hereditary  transmission.  When  thus  acquired,  the  course  and 
various  phenomena  of  syphilis  are  in  nowise  different  from  the  same  affec- 
tion in  the  adult.  A  child  may  become  inoculated  with  syphilis  by  kissing 
persons  with  oral  or  labial  syphilides,  such  as  mucous  patches,  fissures,  and 
ulcers,  or  it  may  acquire  it  from  nursing  its  syphilitic  mother  or  nurse. 
The  possibility  of  acquiring  the  disease  by  vaccination  must  also  be  remem- 
bered, although  at  the  present  day  non-humanized  virus  is  almost  exclu- 
sively used,  and  such  an  accident  can  only  occur  through  the  grossest  and 
most  culpable  carelessness. 

There  is  also  the  possibility  of  contamination  through  criminal  assault, 
perpetrated  by  either  male  or  female  examples  of  depravity.  The  author 
has  seen  four  cases  of  syphilis  in  children  acquired  in  this  manner.  These 
instances  have,  however,  no  bearing  upon  congenital  syphilis,  save  that 
great  care  is  to  be  exercised  in  differentiating  the  two.  An  error  in  diag- 
nosis in  a  ease  of  this  kind  might  seriously  compromise  an  innocent  person, 
on  the  one  hand,  or  allow  a  guilty  one  to  escape,  upon  the  other. 

In  the  case  of  alleged  vaccinal  syphilis  great  care  should  be  taken,  else 
an  innocent  operator  may  be  held  responsible  for  the  sins  of  the  child's 
parents.  It  is  to  be  remembered  that  a  diagnosis  is  difficult  without  a 
knowledge  of  the  natural  course  of  syphilis.  A  more  or  less  typic  course 
of  syphilitic  phenomena,  following  a  chancre,  or,  at  least,  following  primary 
adenopathy,  is  the  only  positive  proof  of  acquired  syphilis,  be  the  subject 
old  or  young. 

Methods  of  Acquieing  Congenital  Syphilis. — The  methods  of  ac- 
quiring syphilis  by  heredity  have  already  been  studied  to  some  extent.  It 
is  held  by  many  that  either  parent  may  transmit  syphilis  to  the  child,  al- 
though, so  far  as  the  father  is  concerned,  the  question  of  his  power  to 
procreate  a  syphilitic  child  without  first  infecting  the  mother  is  still  suh 
juclice.  The  presence  of  the  syphilitic  microbe  is  probably  incompatible 
with  the  life  of  the  spermatozoa;  but,  until  the  germ  of  syphilis  has  been 
absolutely  demonstrated,  we  can  only  claim  theoretically  its  necessity  in 
this  particular  method  of  transmission.     The  most  plausible  view  is  that, 

(455) 


456  CONGENITAL    AXD   ACQUIEED    SYPHILIS    IN    CHILDREN. 

while  the  jDresence  of  the  syphilitic  germ  is  necessary  in  order  that  the 
semen  should  be  inoculable,  its  presence  is  "unnecessary  in  order  that  the 
father  should  impress  the  fetus  with  conditions  which,  while  not  specifically 
syphilitic,  are  none  the  less  derivatives  of  that  disease.  This  results  from 
the  fact  that  the  spermatozoa  of  a  man  who  is  in  the  full  flower  of  syphilis 
have  been  so  modified  that  they  are  incapable  in  most  instances  of  gen- 
erating a  healthy  child.  This  is  still  more  pertinent  when  the  father  is  in 
the  stage  of  sequels.  The  child  need  not  necessarily  be  affected  by  the 
ordinary  phenomena  of  syphilis,  but  may  present  certain  perversions  of 
growth  and  nutrition  not  ordinarily  considered  to  be  syphilitic.  That 
syphilis  may  so  impress  the  spermatozoa  that  the  child  may  be  cachec- 
tic and  ill  nourished,  although  not  actually  syphilitic,  is  probably  true.  It 
is  probable  also  that  the  syphilitic  impress  is  liable  to  appear  as  rickets 
or  scrofulosis — and  perhaps  a  tubercular  tendency — in  the  child.  Inde- 
pendently of  theoretic  reasoning,  it  is  a  positive  fact  that  the  children  of 
apparently  healthy  mothers,  by  syphilitic  fathers,  are  often  affected  by 
certain  conditions  of  malnutrition  that  are  singularly  benefited  by  antisyph- 
ilitic  treatment,  and  which  are  probably  "attenuated  syphilis."  That  the 
mothers  are  not  really  syphilitic,  is,  of  course,  an  open  question,  but  in  a 
large  proportion  of  cases  the  evidence  is  in  their  favor.  As  already  indi- 
cated, if  the  child  really  has  unequivocal  syphilis,  the  author  believes  that 
it  has  become  infected  via  the  maternal  circulation.  He  cannot  accept 
"conceptional  syphilis"  as  described  by  Fournier^:  i.e.,  infection  of  the 
mother  via  the  ovum. 

It  is  an  indisputable  fact  that,  when  the  mother  is  syphilitic  at  the 
time  of  conception,  the  offspring  rarel}^,  if  ever,  escapes.  Her  power  of 
transmitting  the  disease  lasts  much  longer  than  that  of  the  father,  as  may 
be  readily  explained  if  we  stop  to  consider  the  intimate  anatomic  and  physio- 
logic relations  existing  between  the  fetus  in  ute.ro  and  its  mother.  The 
exception  of  the  mother  who  becomes  pregnant  while  healthy,  and  does  not 
become  infected  with  syphilis  until  the  seventh  month,  is  to  be  borne  in 
mind  in  considering  the  probability  of  the  mother's  infecting  her  child. ^ 
It  is  claimed  by  some  that  syphilis  acquired  at  any  time  during  pregnancy 
cannot  be  conveyed  to  the  fetus  in  utero.  Taylor  says  upon  this  point  that 
"the  syphilis  of  the  mother  cannot  be  conveyed  to  the  fetus  through  the 
utero-placental  circulation."^     The  author  does  not  accept  this. 

A  case  recently  observed  by  the  author  supports  the  contrary  view.  In 
this  instance  the  father  developed  syphilis  at  the  third  month  of  his  wife's 
pregnancy.  He  communicated  the  disease  to  her  and  she  ran  a  typic 
course  of  syphilis.     The  child  was  still-born  at  the  seventh  month,  and 


^  "Syphilis  et  Manage." 

-  Diday,  "De  la  Syphilis  des  Noiiveaux-nes." 

^  "Venereal  Diseases/'  Bumstead  and  Taylor,  p.  805. 


METHODS    OF    ACQUIRIXG    COXGENITAL    SYPHILIS.  457 

presented  indisputable  evidences  of  syphilis.     A  case  recently  reported  hj 
Ziessl  is  of  similar  character.^    It  was  essentially  as  follows: — 

Case. — A  young  married  man  in  the  commencement  of  the  month  of  April  had 
connection  with  his  wife  for  the  last  time.  The  menses  remained  away,  and  the  wife 
proved  to  be  pregnant.  On  the  12th  day  of  April  he  had  connection  with  another 
woman,  and  contracted  syphilis  from  her.  The  sore  healed  rapidly,  but  an  induration 
developed  which  remained  a  considerable  time.  As  he  believed  that  without  a  sore  he 
could  not  infect,  he,  on  the  25th  of  May,  recommenced  intercourse  with  his  wife. 
She  contracted  syphilis,  and  on  the  31st  of  December  was  delivered  of  a  child.  It 
showed  indisputable  evidences  of  hereditary  syphilis,  and  died  soon  afterward. 

It  has  been  demonstrated  that  the  female  may  procreate  syphilitic 
children  long  after  she  has  lost  the  power  of  infecting  a  healthy  man. 

As  a  matter  of  practical  importance  it  had  best  be  remembered  that, 
while  it  remains  to  be  positively  shown  that  either  parent  may  infect  the 
child  independently  of  the  other,  cases  sometimes  occnr  that  seem  to  prove 
its  truth,  and  until  the  question  is  absolutely  settled  it  is  best  to  be  cautious, 
and  remain  upon  the  safe  ground  of  conservatism. 

Inasmuch  as  such  diseases  as  small-pox  have  been  communicated 
through  the  mother  to  the  fetus  in  utero,  there  would  seem  to  be  no  good 
reason  why  syphilis  cannot  be  transmitted  in  like  manner. 

One  of  the  best  articles  so  far  published,  bearing  upon  the  possibility 
of  syphilis  acquired  during  pregnancy  affecting  the  fetus,  was  from  the 
pen  of  8imes.^  This  author  has  presented  his  views  so  clearly  and  forcibly 
that  they  are  Avell  worth  quoting  verbatim: — 

The  existence  of  the  hereditary  form  of  syphilis  was  first  definitely  pointed 
out  by  Paracelsus,  in  the  year  1536,  and  since  then  it  has  received  most  careful 
consideration  at  the  hands  of  numerous  writers.  In  fact,  its  study,  owing  to  the  many 
differences  between  the  hereditary  and  acquired  forms  of  syphilis,  has  become  almost 
a  special  branch  of  investigation.  In  considering  the  etiology  of  this  affection  it  is 
found  that  many  and  various  explanations  had  been  given  by  the  early  writers. 
Even  at  the  present  time  several  points  are  still  undecided.  Much  of  the  diversity 
of  opinion  is  due  to  the  many  difficulties  and  peculiar  nature  of  the  investigation. 
The  following  conclusions,  however,  have  been  reached:  — 

1.  A  syphilitic  father  may  procreate  a  syphilitic  child. 

2.  A  syphilitic  mother  may  give  birth  to  a  syphilitic  child. 

3.  Both  parents  being  syphilitic,  their  offspring  will  probably  be  syphilitic. 

4.  The  mother  contracting  syphilis  during  gestation  may  transmit  the  disease 
to  the  fetus,  provided  constitutional  contamination  has  occurred. 

The  first  of  these  propositions  has  not  been  generally  accepted;  the 
second  and  third  are  accepted  without  question,  providing,  in  the  case 
of  conclusion  I^o.  3,  the  mother  is  infected  before  conception  occurs; 
the  last  conclusion  has  not  been  so  favorably  received;  more  especially 
as  it  is   denied  by  Kassowitz,   wdiose  investigations  into   the   etiology   of 

^  Wiener  medicinische  Presse. 

-J.  H.  C.  Simes,  The  Polyclinic,  Philadelphia,  December,  1883. 


458  COXGEKITAL   AND   ACQUIEED    SYPHILIS    IN    CHILDKEN. 

hereditary  syphilis  liave  been  very  elaborate.  He  concludes,  from  the  study 
of  many  cases,  that  a  mother  acquiring  syphilis  during  gestation  does 
not  transmit  the  disease  to  her  healthy  fetus,  and  he  also  claims  that  this 
view  is  much  strengthened  by  the  circumstance  that  his  investigations  in  • 
the  opposite  direction  led  him  to  the  conclusion  that  a  non-syphilitic 
mother  is  capable  of  giving  birth  to  a  syphilitic  child.  The  fetus,  he  says, 
-'cannot  transmit  syphilis  to  the  mother  through  the  placental  circulation, 
and  in  all  cases  where  the  mother  becomes  syphilitic  during  pregnancy,  the 
disease  originated  in  some  other  manner."  The  opinions  advanced  by  Kasso- 
witz  upon  this  subject  have  not,  however,  been  accepted  by  most  writers. 
Their  objections  are  based  largely  upon  clinical  observation:  i.e.,  upon  cases 
'  in  which  the  history  has  been  known  from  the  beginning  to  the  termination. 
Simes  says  upon  this  point: — 

It  is  just  here,  however,  that  the  most  experienced  are  liable  to,  and  frequently 
do,  fall  in  error,  not  in  any  way  due  to  their  want  of  skill,  but  owing  to  deception, 
or,  at  times,  no  doubt,  to  ignorance,  on  the  part  of  the  individual.  Where  the  nature 
of  the  investigation  is  of  so  peculiar  a  character  as  endeavoring  to  ascertain  the 
etiology  of  a  disease  which  is  considered  by  those  contracting  it  a  disgrace,  deception 
is  not  to  be  wondered  at,  and,  where  the  early  symptoms  of  the  disease  are  fre- 
quently so  slight  and  imperceptible  that  not  only  the  patient,  but  the  surgeon  himself, 
may  overlook  them,  ignorance  of  their  existence  is  possible.  Therefore  it  must  be 
admitted  that  in  the  most  carefully  reported  cases  there  is  frequently  room  for  con- 
troversy. After  duly  considering  both  sides  of  the  subject,  I  am  inclined  to  the 
opinion  that  syphilis  contracted  during  pregnancy  may  be  transmitted  by  the  mother 
to  a  previously-healthy  fetus,  provided  the  affection  in  the  mother  has  passed  beyond 
the  initial  lesion  and  is  made  manifest  by  constitutional  symptoms.  This  conclusion 
has  been  reached  from  a  physiologic  and  historic  study,  rather  than  from  clinical 
observation  on  the  subject.  In  order  to  make  any  reasoning  in  this  matter  secure,  it 
would  be  necessary  to  establish  the  nature  of  the  syphilitic  virus,  and  here  it  must 
be  admitted  that  much  diversity  of  opinion  exists  among  the  most  reliable  authorities. 
I  agree  fully  with  those  who  hold  that  this  virus  is  a  material,  and  probably  a 
demonstrable,  substance,  but  its  exact  nature  I  am  not  at  present  able  to  describe;  it 
may  be  a  diseased  cell,  an  infected  particle  of  protoplasm,  or  a  micrococcus;  but 
that  it  is  some  degraded  anatomic  element  of  the  organism,  either  holding  or  con- 
stituting the  virus,  and  having  the  power  of  transmitting  it  to  another  organism,  all 
clinical  experience  and  experimental  pathology  lead  me  to  infer.  It  is  beyond  doubt 
that  the  blood  of  a  person  affected  with  constitutional  syphilis  contains  the  virus, 
and  is  capable,  when  inoculated  upon  a  non-syphilitic  individual,  of  producing  the 
disease.  This  virus  being,  as  I  believe,  a  material  substance,  it  must  exist  in  the 
blood,  either  as  a  separate  element  or  an  organism.  In  either  case  the  inherent 
power  possessed  by  the  white  blood-corpuscle  of  surrounding  or  incorporating  within 
itself  any  material  substance  with  which  it  comes  in  contact,  leads  me  to  conclude 
that  these  corpuscles  are  the  chief,  if  not  the  only  means,  by  which  the  virus  is 
transmitted  from  one  organism  to  another.  When  the  anatomic  and  histologic  rela- 
tions of  the  placental  and  uterine  connection  are  examined,  it  is  seen,  from  the  most 
recent  investigations,  that  no  direct  communication  exists  between  the  circulation 
of  the  placental  and  maternal  blood.  From  the  anatomic  structure  of  the  parts,  it  has 
been  considered  impossible  for  a  material  virus  to  pass  from  mother  to  fetus.  That 
a  direct  communication  is  necessary,  in  order  that  a  material  substance  may  be 
conveyed  from  mother  to  fetus,  I  do  not  believe. 


METHODS    OF    ACQUIEIXG    COJs'GENITAL    SYPHILIS.  459 

Eeferring  again  to  the  white  blood-corpuscle- — the  probable  carrier  of 
the  infection — it  is  known  to  possess  the  vital  property  of  movement  or 
migration,  and  also  has  the  power  of  penetrating  and  passing  through  the 
protoplasmic  wall  of  the  blood-vessels.  These  physiologic  and  histologic 
conditions  existing  and  being  capable  of  demonstration,  a  direct  communi- 
cation of  maternal  and  fetal  circulation  is  not  required  in  order  that  a 
material  virus  may  pass  from  one  to  the  other.  The  white  blood-corpuscles, 
containing,  or  constituting,  as  the  case  may  be,  the  morbific  germ  of  syph- 
ilis, may  pass  directly  through  the  vascular  wall  and  infect  the  fetus.  The 
])ossibility,  or  rather  the  certainty,  of  the  white  blood-corpuscle's  having  the 
]30wer  of  carrying  material  substances  from  the  maternal  to  the  fetal  cir- 
culation has  been  demonstrated  by  the  experimental  researches  of  several 
investigators.  When  minute  insoluble  particles,  such  as  cinnabar  or  indigo, 
are  injected  into  the  blood-vessels  of  a  living  pregnant  animal,  and  the 
animal  killed  after  a  varying  period,  an  examination  of  the  fetuses  within 
the  uterus  shows  the  white  corpuscles  of  their  blood  to  contain  some  of 
the  particles  that  were  injected  into  the  blood-vessels  of  the  mother. 

Simes  says,  anent  this  question: — 

Therefore,  if  it  is  possible  for  such  comparatively-large  and  appreciable  particles 
to  pass  from  one  organism  to  another,  through  the  placenta,  it  is  not  unreasonable  to 
conclude  that  it  is  possible,  or  even  very  probable,  that  the  virus  of  syphilis,  which 
has  as  yet  escaped  our  observation  when  sought  for  with  the  highest  powers  of  the 
microscope,  may  in  a  similar  manner  be  transmitted.  These  experiments  would 
certainly  indicate  that  it  is  immaterial  whether  an  immediate  and  direct  vascular 
communication  does  or  does  not  exist  between  mother  and  fetus,  although  this  question 
seems  to  be  the  only  one  which  investigators  have  endeavored  to  determine,  in  order 
to  explain  fetal  infection.  The  vital  ameboid  movement,  the  inherent  power  of  incor- 
porating within  itself  foreign  substances,  and  the  acknowledged  power  of  passing 
through  the  protoplasmic  wall  of  the  blood-vessels,  are  all  attributes  possessed  by  the 
white  blood-corpuscle,  and  are,  I  think,  sufficient  to  explain  the  manner  and  possibility 
of  fetal  contamination. 

Morrow's  conclusions  upon  hereditary  syphilis  are  as  folloAv: — 

1.  A  syphilitic  man  may  beget  a  syphilitic  child,  the  mother  remaining  exempt 
from  all  visible  signs  of  the  disease;  the  transmissive  power  of  the  father  is,  how- 
ever, comparatively  restricted. 

2.  A  syphilitic  woman  may  bring  forth  a  syphilitic  child,  the  father  being  per- 
fectly healthy;  the  transmissive  power  of  the  mother  is  much  more  potent  and  pro- 
nounced, and  of  longer  duration  than  that  of  the  father. 

3.  When  both  parents  are  syphilitic,  or  the  mother  alone,  and  the  disease  re- 
cently acquired,  the  infection  of  the  fetus  is  almost  inevitable;  the  more  recent  the 
syphilis,  the  greater  the  probability  of  infection  and  the  graver  the  manifestation 
in  the  offspring. 

4.  While  hereditary  transmission  is  more  certain,  when  the  parental  syphilis  is 
in  full  activity  of  manifestation,  it  may  also  be  effected  during  a  period  of  latency 
when  no  active  symptoms  are  present. 

5.  Both  parents  may  be  healthy  at  the  time  of  procreation,  and  the  mother  may 
contract  syphilis  during  her  pregnancy  and  infect  her  child  in  ntero.     Contamination 


460  CONGENITAL    AND    ACQUIEED    SYPHILIS    IN    CHILDEEN. 

of  the  fetus  during  pregnancy  is  not  probable  if  the  maternal  infection  takes  place 
after  the  seventh  month  of  pregnancy. 

Fetal  and  Placental  Changes  from  Syphilis.  —  The  changes  in  the 
fetus  resulting  from  the  sypliilitic  infection  or  impression  are  of  vital  im- 
portance, and  often  decide  the  cjuestion  as  to  the  birth  of  a  living  syph- 
ilitic child.  The  ovum  may  he  blighted  early  in  the  course  of  utero-gesta- 
tion  and  be  cast  off,  or  absorbed,  or  it  may  develop  to  a  greater  or  less  ex- 
tent, according  to  the  severity  with  which  the  syphilitic  infection  manifests 
itself.  The  disease  may  manifest  itself  in  several  ways,  and  sometimes  in 
a  rather  obscure  fashion.  A  general  shriveling  or  dwarfing  of  the  structure 
of  the  fetus  may  occur,  with  resulting  death  and  consequent  abortion. 
Serious  visceral  lesions  sometimes  occur  and  destroy  life:  e.g.,  the  author 
recalls  a  case  in  which  a  woman  miscarried,  and  was  delivered  of  a  still- 
born child  whose  liver  was  so  enormously  hypertrophied  as  to  cause  serious 
difficulty  in  delivery.  Intra-uterine  hydrocephalus  is  an  occasional  result 
of  syphilis.  The  author  has  had  occasion  to  perform  craniotomy  upon  a 
case  of  this  kind.  He  also  had  the  privilege  of  assisting  Dr.  Munde  in  a 
similar  operation  at  the  New  York  Maternity  Hospital  some  years  ago. 

Disease  and  malformation  of  the  infantile  osseous  system  are  frequent 
results  of  syphilis,  and  it  is  the  author's  conviction  that  many  congenital 
deformities  depend  upon  imperfect  development,  resulting  either  from  dis- 
tinct intra-uterine  syphilis  or  the  nutritive  perversions  produced  by  "attenu- 
ated syphilis."  These,  however,  are  the  more  obscure  manifestations  of  the 
disease. 

Apoplectic  effusions  often  occur  in  the  syphilitic  fetus,  and,  if  all 
aborted  syphilitic  children  were  examined  critically,  much  light  might  be 
shed  upon  the  effects  of  syphilis  upon  the  vascular  system. 

Well-marked  eruptions  are  apt  to  occur  upon  the  fetus  in  utero,  and 
most  syphilitic  fetuses  will  present  some  unmistakable  external  lesion. 

It  is  exceptional  that  a  woman  in  full  syphilis  succeeds  in  carrying  a 
child  to  term,  even  when  under  quite  active  treatment.  x\bortion  usually 
occurs,  and  is  perhaps  most  often  due  to  death  of  the  fetus,  which  then  acts 
as  a  foreign  body  and  is  cast  off.  It  is  not  unusual,  however,  for  abortion  to 
occur  as  a  result  of  placental  changes.  Placentitis  hemorrhagica,  fatty  and 
waxy  changes  in  the  placenta,  all  interfere  with  its  uterine  attachments 
primarily,  and  secondarily  affect  the  vitality  of  the  fetus  by  interfering  with 
the  interchange  of  nutritive  material  necessary  for  its  sustenance.  Placental 
apoplexy  is  especially  apt  to  bring  on  abortion,  particularly  when  the  blood 
extravasates  upon  its  attached  surface  and  detaches  it  to  a  greater  or  less 
extent.  When  the  hemorrhage  is  parenchymatous,  abortion  is  not  so  likely 
to  occur.  Syphilis  is  one  of  the  most  potent  and  frequent  causes  of  abor- 
tion, and  when  a  female,  however  healthy,  aborts  frequently,  a  suspicion  of 
syphilitic  taint  is  justifiable. 

The  treatment  of  syphilitic  abortion  is  of  necessity  the  administration 


SYPHILIS    HEEEDITAEIA    TARDA.  461 

of  mild  mercurials  throughout  the  course  of  pregnancy.  It  by  no  means 
follows  that,  because  a  woman  aborts  as  a  result  of  syphilis,  she  must  neces- 
sarily give  birth  to  a  syphilitic  child;  hence  it  is  always  Just  and  consci- 
entious to  try  to  carry  the  pregnancy  to  full  term  if  possible.  The  better 
the  apparent  health  of  the  mother,  and  the  later  the  period  of  the  disease, 
the  more  eminently  proper  such  a  course  becomes. 

When  a  syphilitic  child  goes  on  to  full  term,  which  often  occurs,  it 
may  be  born  a^Dparently  healthy  and  well  nourished,  but,  as  a  rule,  it  de- 
velops symptoms  of  inherited  syphilis  within  a  few  weeks.  In  the  majority 
of  instances  syphilis  develops  before  the  child  is  three  months  old.  In  some 
cases,  however,  some  years  elapse  before  symptoms  are  discovered,  and  then 
they  are  more  or  less  marked.  Cases  have  been  related  in  which  lesions  of 
the  pharynx,  viscera,  and  bones  occurred  in  adult  life  for  the  first  time,  the 
childhood  of  the  patient  having  been  apparently  healthy — syphilis  hered- 
itaria tarda.  It  is  probable,  however,  that  in  these  cases  symptoms  have 
existed  at  an  earlier  period,  but  have  been  overlooked.  There  is  some  clinical 
testimony,  of  more  or  less  doubtful  character,  to  the  effect  that  an  entire 
generation  may  be  skipped  before  the  syphilitic  nutritive  impression  mani- 
fests itself.  Obviously,  such  cases  are  not  really  syphilis,  but  remote  results 
of  the  disease. 

Syphilis  Heeeditaeia  Taeda. — In  a  series  of  lectures  at  the  Hopital 
St.  Louis,  Fournier  called  especial  attention  to  late  hereditary  syphilis.  He 
gives  the  following  interesting  cases  in  support  of  his  view  that  the  first 
manifestations  of  hereditary  syphilis  may  be  after  the  period  of  infancy  and 
even  during  the  period  of  adolescence: — 

1.  A  case  of  interstitial  keratitis  and  double  sarcocele  in  a  child  4  years  of  age. 

2.  A  case  of  a  child,  aged  7  years  and  6  months,  born  of  parents  both  of  whom 
were  syphilitic,  who  suffered  from  brain  syphilis  which  yielded  to  the  iodid  of 
potassium. 

3.  A  case  of  a  man,  24  years  of  age,  who  had  mucous  patches  soon  after  birth, 
but  no  other  symptoms  until  the  age  of  sixteen,  when  he  developed  syphilitic  gumma 
of  the  testis  of  a  diffuse  character  (i.e.,  sarcocele).  At  the  age  of  24  extensive  syphilom- 
atous  deposit  occurred  in  this  patient's  tongue. 

These  cases  are  of  great  interest,  but  the  classification  and  description 
of  the  various  lesions  seen  late  in  life  and  attributed  by  Fournier  to  late 
hereditary  syphilis,  are,  in  general,  certainly  overdrawn.  Were  they  true, 
there  are  very  few  persons  with  peculiarities  of  cranial  or  nasal  structure 
who  would  be  free  from  suspicion  of  hereditary  taint.  Many  patients  with 
precisely  the  same  congenital  characteristics  described  in  some  of  Fournier's 
cases  are  met  with  who  are  suffering  from  severe  acquired  syphilis,  which, 
while  not  impossible,  would  not  be  very  likely  to  occur  were  the  patients 
congenitally  syphilitic. 

In  determining  the  question  of  late  hereditary  syphilis  it  is,  of  course, 
necessary  to  inquire  most  minutely  into  the  family  history.     IsTot  only  the 


462  COXGEXITAL    AXD   ACQUIRED    SYPHILIS    IX    CHILDREX. 

parents,  but  the  brothers  and  sisters  must  be  examined  in  order  to  arrive 
at  a  rational  conclusion.  The  necessity  for  this  careful  inquiry  has  been 
shown  quite  plainly  by  the  observations  of  Hughlings-Jackson,  Avho  has 
demonstrated  conclusively  that  hereditary  syphilis  may  be  plainly  marked 
in  one  member  of  a  family,  while  the  brothers  and  sisters  show  absolutely 
no  traces  of  the  disease. 

As  has  been  already  asserted,  many  cases  of  disturbed  nutrition  termed 
struma  or  scrofulosis  are  probably  syphilitic.  Astley  Cooper  tacitly  ad- 
mitted this  in  his  day.  His  favorite  remedy  for  ''scrofula'''  consisted  of  mer- 
cury bichlorid  in  Huxham's  tincture  of  cinchona-bark.  Hutchinson  appar- 
ently entertains  a  similar  view. 

In  the  majority  of  instances  the  syphilitic  child  is  indelibly  stamped 
with  the  hereditary  impress.  As  a  rule,  it  is  remarkable  for  its  pinched, 
shriveled  appearance,  due  probably  to  a  lack  of  fatty  tissue  from  malnu- 
trition. The  newborn  baby  has  the  look  of  an  old  man,  and,  if  it  lives  long- 
enough,  has  often  the  most  supernatural  look  of  intelligence  that  could 
be  imagined.  This  wise  little  old  man  is  as  remorseless  as  fate  in  divulging 
the  sins  of  his  parents.  He  says  little,  but  expresses  much,  and  is  a  burden 
greater  than  the  "Old  Man  of  the  Sea"  so  long  as  he  lives.  He  is  literally 
persona  non  grata  to  all  concerned. 

Lesions  of  Congenital  Syphilis.  —  If  not  present  at  birth,  lesions 
of  various  kinds  develop  from  time  to  time.  The  author  has  delivered 
children  with  a  well-marked  roseola.  Chaps  and  excoriations  of  the  quasi- 
mucous  surfaces  about  the  genitals,  anus,  and  mouth  are  apt  to  develop, 
and  may  form  true  plaques  muqueuses  or  even  condylomata.  A  "scalded" 
appearance  of  the  anus  is  quite  characteristic.  "Snuffles"  develop  after  a 
time,  and  the  nares  become  so  clogged  up  that  respiration  and  nursing 
are  interfered  with,  and  nutrition  still  further  impaired.  Ozena  may  de- 
velop and  lead  to  necrosis  of  the  nasal  cartilages.  There  is  no  symptom  of 
hereditary  syphilis  that  is  considered  so  characteristic  in  the  minds  of  the 
mass  of  the  profession  as  snuffles.  Apropos  of  this,  the  author  desires  to 
warn  the  young  physician  that,  if  he  begins  diagnosing  hereditary  syphilis 
from  this  symptom  alone,  there  will  be  breakers  ahead.  A  great  number 
of  young  children,  especially  in  such  climates  as  that  of  our  lake-region, 
are  affected  by  catarrh  or  coryza  that  presents  an  excellent  imitation  of 
syphilitic  snuffles.  A  diagnostic  mistake  in  these  cases  will  surely  cause 
serious  trouble,  and  it  is  safer  for  the  physician  to  diagnose  all  cases  as 
catarrh,  meanwhile  treating  them  as  he  sees  fit,  than  to  run  any  risks  in 
diagnosis,  especially  where  an  accurate  diagnosis  might  be  unwelcome. 

A  livid  macular  eruption  is  sometimes  seen,  and  ulcerations  may  form 
about  the  mucous  orifices.  Papular  and  pustular  lesions  are  not  infrequent, 
and  quite  characteristicly  affect  the  palms  and  soles  in  certain  instances. 
Subcutaneous  tubercular  lesions  may  be  seen  in  some  few  cases. 

A  very  peculiar  eruption  occasionally  occurs  in  syphilitic  children  that 


SYPHILIS    HEEEDITAEIA    TARDA.  463 

is  quite  identic  in  its  pliysical  characteristics  with  ordinary  pemphigus  in 
the  adult.  This  "infantile  pemphigus"  is  an  unmistakable  evidence  of 
syphilis.  It  consists  of  an  eruption  of  bullas  or  blebs,  sparsely  distributed 
over  the  skin.  Sometimes  but  one  or  two  buUas  are  present.  It  is  especially 
apt  to  affect  the  palms  of  the  hands  and  soles  of  the  feet.  The  blebs  are 
filled  with  fluid  that  varies  in  its  physical  characters  from  slightly-turbid 
serum  to  pus,  and  is  sometimes  bloody.  When  the  cuticle  ruptures,  the  fluid 
dries  into  a  greenish  crust  and  ulceration  occurs  beneath,  precisely  as  in 
syphilitic  ecthyma  or  rupia. 

It  has  been  claimed  that  infantile  pemphigus  may  result  from  simple 
cachexia,  but  the  evidence  of  this  is  dubious,  and  it  may  be  generally  ac- 
cepted as  a  positive  evidence  of  syphilis.  When  a  syphilitic  child  develops 
pemphigus,  a  severe  type  of  disease  is  evidenced,  and  the  case  is  usually 
hopeless.  A  severe  case  in  a  3-month-old  infant  recently  seen  by  the  author 
made,  however,  a  good  recovery. 

The  epithelial  appendages  of  the  body,  such  as  the  hair  and  nails,  are 
not  so  likely  to  become  affected  in  congenital  syphilis  as  in  the  adult,  but 
a  brittle,  lusterless  condition  of  the  nails  is  occasionally  noted.  As  Hutchin- 
son has  shown,  the  nails  may  be  repeatedly  shed,  or  they  may  split  and  be- 
come ragged  in  appearance.  They  may  even  become  affected  by  suppura- 
tion or  onychia.^ 

It  has  been  generally  accepted  that  the  osseous  lesions  of  children  are 
insignificant  as  compared  with  the  same  changes  in  the  adult  syphilitic. 
This,  however,  is  a  mistake.  The  author  has  been  so  fortunate  as  to  observe 
a  considerable  number  of  bone-lesions  in  children.  One  of  the  most  fre- 
quent lesions  observed  in  the  cases  of  congenital  syphilis  at  the  N.  Y. 
Charity  Hospital  was  syphilitic  "inflammation"  of  the  bones.  It  was  the 
exception,  rather  than  the  rule,  that  serious  visceral  lesions  were  unaccom- 
panied by  osseous  troubles.  Taylor  has  called  especial  attention  to  lesions 
of  the  bones  in  congenital  syphilis.^  He  has  shown  that  the  most  frequent 
seat  of  the  osseous  lesions  is  the  diaphyso-epiphysial  junction  of  the  long 
bones,  certain  bones,  however,  being  affected  with  especial  frequency.  This 
is  explained  by  the  fact  that  the  processes  of  growth  and  nutrition  are 
most  active  at  the  junction  of  the  diaphysis  and  epiphysis  of  all  bones. 
The  possible  dependence  of  certain  cases  of  rickets  upon  hereditary  syphilis 
is  a  question  which,  although  as  yet  sub  judice,  is  of  the  greatest  interest 
and  importance.  Parrot  even  goes  so  far  as  to  claim  a  syphilitic  orip-in  for 
all  cases  of  rickets.  While  this  proposition  is  untenable,  the  author  is 
inclined  to  believe  that  syphilis  is  responsible  for  quite  a  proportion  of 
cases.  It  is  certainly  not  fair  to  ignore  Parrot's  series  of  one  hundred  cases 
of  rickets,  of  which  ninety-one  were  unequivocally  syphilitic.     Kassowitz 


^  Hutchinson,  "Pathological  Transactions,"  xii,  259. 
=  R.  W.  Taylor,  "Bone  Syphilis  in  Children." 


464  COXGEXITAL   AXD   ACQUIEED    SYPHILIS    IX    CHILDKEX. 

and  several  other  German  authorities  claim  that  nearly  all  syphilitic  chil- 
dren become  rachitic,  and  Fournier,  of  the  French  school,  believes  that 
syphilis  has  much  to  do  with  the  etiology  of  rickets.  If  this  theory  be  well 
grounded, — and  it  must  be  admitted  that  syphilis  and  its  derivatives  pro- 
duce profound  nutritive  perversions, — congenital  syphilis  and  the  inherited 
syphilitic  diathesis  are  necessarily  responsible  for  many  deformities. 

In  syphilitic  osteitis  in  infants  the  bones  are  usually  more  or  less 
uniformly  enlarged,  although  in  certain  instances  the  periosteum  seems 
chiefly  afEected.  Suppuration  is  infrequent,  but  is  described  by  Bouchut 
as  a  result  of  softening  of  the  cartilages  of  the  epiphysis.^  Xecrosis  is  not 
very  infrequent. 

The  most  important  of  all  the  manifestations  of  hereditary  syphilis 
are  the  lesions  of  the  viscera.  The  processes  of  growth  and  nutrition  in 
the  infant  are  very  active,  and  constructive  changes  are  especially  favored. 
These  circumstances  are  particularly  conducive  to  the  proliferation  of  young 
connective  tissue  about  the  parenchyma  of  the  viscera.  These  interstitial 
proliferations  are  usually  diffuse,  circumscribed  cell-deposits  being  excep- 
tional. Such  cases,  however,  have  been  observed.  Any  or  all  of  the  viscera 
may  be  involved,  the  connective-tissue  changes  being  especially  apt  to  affect 
the  liver,  spleen,  and  kidneys. 

There  is  in  syphilitic  newborn  children  a  marked  tendency  to  apoplectic 
effusions  in  various  situations,  particularly  in  the  meninges  of  the  brain 
and  probably  also  the  cord.  The  condition  known  as  cephalhematoma  is 
especially  apt  to  occur  in  syphilitic  children,  in  whom  the  vessels  seem 
to  be  characterized  by  great  tenuity.  If  labor  be  at  all  difficult,  or  if 
forceps  be  used,  there  is  great  danger  of  intracranial  or  sitbpericranial  effu- 
sions. The  author  has  noted  5  cases  of  meningeal  hemorrhage  in  new- 
born syphilitic  children — verified  by  autopsy — and  6  cases  of  cephalhema- 
toma, 4  of  which  were  undoubtedly  syphilitic.  In  1  case  the  child  developed 
a  cephalhematoma  soon  after  birth  that  absorbed  in  a  few  weeks.  During 
the  fourth  week  the  child  developed  convulsions  and  died.  On  autopsy 
extensive  changes  in  all  the  viscera  were  noted,  and  upon  the  surface  of  the 
brain  a  large  clot  from  a  ruptured  meningeal  vessel  was  found.  In  1  of  the 
author's  cases  of  meningeal  hemorrhage  the  child  was  found  dead  by  its 
mother's  side,  and  a  suspicion  of  foul  play  was  entertained.  The  autopsy, 
however,  sjiowed  an  extensive  meningeal  hemorrhage. 

Cases  of  sudden  death  in  syphilitic  children  have  been  occasionally 
noted  by  other  observers,  but  there  seems  to  have  been  no  autopsy  in  the 
majority  of  instances,  at  least  no  explanation  for  these  cases  has  been  given, 
so  far  as  the  author  is  aware.  It  is  probable  that  some  of  them  have  been 
due  to  meningeal  hemorrhage.  This  is  of  medico-legal  importance,  and 
should  be  remembered. 


Bouchut:    "^Maladies  des  Enfants  Xouveaux-nes." 


SYPHILIS    HEREDITAEIA   TAEDA.  465 

An  hemorrhagic  tendency  has  been  noticed  in  another  form  in  syph- 
ilitic children: — 

Case  1. — Andronico  reports  the  case  of  an  infant  born  of  a  woman  who,  in  the 
second  month  of  pregnancy,  had  a  chancre  on  the  vulva.  From  the  first  days  of  life 
the  child  had  coryza  and  marked  icterus;  soon  afterward  numerous  points  of  a 
copper-red  color  appeared  on  the  skin,  and  obstinate  hemorrhage  took  place  from  the 
umbilical  cord.    The  child  died  on  the  ninth  day.^ 

Another  case  is  reported  by  de  Lnca: — 

Case  2. — A  woman  acquired  syphilis  from  her  husband,  and  some  years  later 
gave  birth  to  a  child.  The  infant  suffered  from  pemphigus,  and  soon  after  the  bullae 
became  filled  with  blood,  and  petechias  appeared  on  the  legs.  Finally,  uncontrollable 
hemorrhage  took  place  from  the  gums  of  the  lower  jaw,  the  umbilical  cicatrix,  and 
the  intestines,  and  the  child  soon  died.^ 

Children  are  apt  to  develop  hydrocephalus  as  a  result  of  syphilitic  in- 
heritance. The  author  recalls  to  mind  a  family  in  which  two  successive 
children  died  of  this  disease  as  a  result  of  congenital  syphilis.  The  so- 
called  rachitic  appearance  of  the  skull  is  often  a  manifestation  of  syphilis. 
The  extreme  pathologic  conditions  of  the  brain  in  congenital  cerebral  syph- 
ilis are  well  shown  by  the  following  case  reported  by  Dr.  Angel  Money^: — 

Case. — Chronic  syphilitic  meningitis,  arteritis,  cerebral  atrophy,  and  sclerosis  in 
a  boy  aged  4:  He  was  first  seen  at  the  age  of  eleven  months,  suffering  from  hydro- 
cephalus. The  skull  was  natiform,  the  root  of  the  nose  depressed,  the  spleen  enlarged, 
and  there  were  signs  of  disseminated  choroiditis.  Syphilitic  taint  was  discovered  in 
every  member  of  the  family.  The  boy  improved  and  seemed  to  be  almost  well  until 
August  18,  1888,  when  left  spastic  hemiplegia  developed.  On  October  11  he  lost  his 
speech  and  developed  right  spastic  hemiplegia,  and  on  the  19th  he  died.  At  the 
necropsy  the  brain  and  dura  mater  were  found  to  be  adherent  everywhere,  but  the 
adhesions  could  be  separated.  The  arteries  were  much  diseased,  so  was  also  the  brain- 
substance.  The  atrophy  and  sclerosis  were  most  marked  in  regions  supplied  by  the 
diseased  arteries.  The  dura  mater  was  four  lines  thick  in  the  temporal  regions,  and , 
resembled  a  fibroma  in  structure.  The  ependyma  was  granular  in  appearance,  due  to 
the  formations  of  granulations  composed  of  small,  round  nuclei;  and  the  structure 
was  of  considerable  density.  Dr.  Money  also  exhibited  the  brain  of  a  microcephalic 
child,  showing  atrophy  and  sclerosis  of  the  left  hemisphere  without  disease  of  the 
arteries  or  membranes,  but  yet  of  syphilitic  origin.  The  child  could  not  stand,  sit,  or 
talk,  and  all  the  limbs  were  weak  and  spastic,  but  the  left  arm  least  so.  Death  oc- 
curred at  the  age  of  sixteen  months,  and  the  brain  weighed  fourteen  ounces. 

It  is  probable  that  congenital  syphilis  has  a  more  or  less  marked  in- 
fluence in  the  causation  of  tubercular  meningitis.  The  congenital  taint 
may  not  give  positive  evidence  of  its  presence  by  a  development  of  un- 
equivocal syphilitic  disease,  and  yet  may  so  impair  nutrition  as  to  favor  the 
development  of  tubercle,  in  case  of  exposure  to  infection.     The  syphilitic 


^  Giornale  Italiano  delle  Malattie  e  della  Pell.,  August,  1886. 
-  Giornale  Italiano  delle  Malattie  e  della  Pell.,  August,  1886. 
'  "Transactions  of  the  Pathological  Society,"  London,  1888. 


466  CONGENITAL   AND   ACQUIRED    SYPHILIS    IN    CHILDEEN. 

soil  is  one  in  which  the  tubercular  bacillus  will  flourish,  and  the  remote 
conditions  of  malnutrition  inherited  from  syphilitic  parents  are  therefore 
a  constant  invitation  to  tubercular  infection. 

Geneeal  Chaeactees. — The  most  accurate  description  of  the  symp- 
toms of  congenital  syphilis  that  has  ever  been  given  is  that  of  Mr.  Jona- 
than Hutchinson.  The  syphilitic  countenance  as  described  by  him  is  quite 
characteristic,  and  his  description  of  the  teeth  in  congenital  syphilis  is 
classic.  The  evidences  given  by  the  teeth  cited  by  him  are  not  pathogno- 
monic nor  are  they  always  present  even  when  positive  signs  of  syphilis  exist, 
but  in  general  they  are  very  valuable. 

The  permanent  teeth,  instead  of  being  regular  and  symmetrically  de- 
veloped, are  irregular,  notched  and  pegged  in  appearance,  and  the  con- 
formation of  the  alveolar  arch  is  imperfect.  The  two  upper  central  incisors 
are  Hutchinson's  "test  teeth."  They  are  short,  vertically  notched,  narrow, 
and  rounded  at  their  corners. 

Hutchinson  further  says: —  '    • 

Next  in  value  to  the  malformation  of  the  teeth  are  the  state  of  the  patient's 
skin,  the  conformation  of  his  nose,  and  the  contour  of  his  forehead.  The  skin  is 
almost  always  thick,  pasty,  and  opaque.  It  also  shows  pits  and  scars,  the  relics  of 
former  eruptions,  and  at  the  angles  of  the  mouth  are  radiating  linear  scars,  running 
out  into  the  cheeks.  The  bridge  of  the  nose  is  almost  always  low,  and  broader  than 
usual;  often  it  is  remarkably  sunken  and  expanded.  The  forehead  is  usually  large 
and  protuberant  in  the  region  of  the  frontal  eminences;  often  there  is  a  well-marked 
broad  depression  a  little  above  the  eyebrows.  The  hair  is  usually  dry  and  thin,  and 
now  and  then  the  nails  are  broken  and  splitting  into  layers. 

Interstitial  keratitis  is  pathognomonic  of  inherited  taint,  and,  when 
coincident  with  the  syphilitic  type  of  teeth,  puts  the  diagnosis  beyond  doubt. 

There  is  one  peculiarity  about  badly-nourished  syphilitic  children  that 
has  especially  impressed  the  author,  and  that  is  the  appearance  of  the  hands 
and  feet.  These  members  are  scrawny  and  wrinkled,  and  resemble  in  min- 
iature those  of  an  aged  person.  The  skin  has  the  appearance  presented  by 
the  integument  of  a  part  that  has  been  overdistended  from  edema,  after 
the  serous  effusion  has  become  absorbed.  Should  the  syphilitic  child  live, 
it  will  be  observed  to  have  a  marked  tendency  to  splay-foot,  talipes,  and  such 
deformities.  The  general  dusky  appearance  of  newborn  syphilitic  infants 
is  also  quite  striking  in  most  cases,  and  is  due  to  a  generally  defective  vas- 
cular tonus. 

Peognosis. — The  prognosis  of  congenital  syphilis  is  very  unfavorable 
— fortunately  so,  in  the  author's  opinion.  The  earlier  the  eruptions  or  other 
symptoms  appear,  the  greater  the  danger.  Marked  eruptions  occurring 
shortly  after  birth  indicate  a  fatal  prognosis.  Severe  and  early  ozena  in 
badly-nourished  children  is  of  like  import.  Marked  visceral  lesions  and 
apoplectic  effusions  are  always  fatal.  Lesions  of  the  bones,  if  unaccom- 
panied by  marked  visceral  changes,  are  not  so  serious.    In  cases  of  enteritis 


TREATMENT    OF    CONGENITAL    SYPHILIS.  467 

syphilitica,  a  lesion  first  described  by  Lancereaux,  there  is  no  hope  of  saving 
the  child. 

In  the  face  of  the  unfavorable  prognosis  of  hereditary  syphilis,  it  is 
some  consolation  to  know  that,  as  a  rule,  a  syphilitic  child  is  better  dead, 
for  it  is  a  constant  danger  to  its  friends,  and  its  life  is,  at  best,  but  a  miser- 
able one.  Sometimes,  however,  a  syphilitic  child  becomes  fat  and  healthy 
under  proper  treatment,  and  sometimes  without  it.  This  is  borne  out  by 
the  following  case  of  the  author's: — 

Case. — The  male  child  of  parents  who  were  both  syphilitic  presented  the  char- 
acteristic aged  appearance  of  the  syphilitic  infant  at  birth.  Double  talipes  was  present, 
and  altogether  there  seemed  to  be  a  most  deplorable  prospect  for  the  child.  An  un- 
favorable prognosis  was  given,  and  as  it  seemed  useless  to  prescribe  for  the  infant — 
which  was  in  nowise  suffering — nothing  was  prescribed  save  inunctions  of  codliver-oil. 
The  child  is  now  6  months  old,  and  the  author  was  greatly  surprised  when,  a  day  or 
two  since,  the  little  patient  ^%as  brought  in  by  its  mother.  The  infant  was  not 
only  apparently  healthy  and  well  nourished,  but  its  feet  were  very  nearly  normal 
in  appearance,  as  a  result  of  persistent  manipulation  by  the  mother. 

Treatment. — The  treatment  of  congenital  syphilis  is  to  be  carried  out 
in  two  ways,  according  to  the  age  of  the  child,  viz.:  1.  By  direct  medication 
of  the  child.     2.  Indirect  medication  through  the  system  of  the  mother. 

The  best  internal  remedy  for  the  child  is  the  hydrargyrum  cum  creta 
in  doses  from  1  to  3  or  4  grains  three  times  daily.  In  very  young  children 
inunctions  of  mercurial  ointment  or  the  oleate  of  mercury  in  very  mild 
strength  must  be  depended  upon.  A  good  plan  is  to  spread  a  piece  of  blue 
ointment,  the  size  of  a  large  filbert,  upon  the  fiannel  binder  once  daily. 
The  delicate  skin  of  the  child  absorbs  this  quite  readily.  Daily  cleansing 
with  soap  and  water,  and  frequent  shifting  of  the  position  of  the  band,  are 
necessary  to  avoid  irritation.  The  soles  of  the  feet,  axillae,  and  flexures  of 
the  joints  are  also  eligible  situations  for  inunctions. 

In  older  children  the  bichlorid  of  mercury  may  be  given  in  small  doses, 
in  combination  with  some  vegetable  bitter,  like  Huxham's  tincture.  Tablet 
triturates — mercury  with  chalk,  protiodid,  mild  chlorid,  or,  best  of  all,  the 
tannate — are  also  useful. 

The  general  condition  is  always  to  be  borne  in  mind  in  treating  con- 
genital syphilis — anemia  especially  must  be  guarded  against.  Codliver-oil 
and  iron  will  always  be  of  benefit.  The  syrup  of  the  iodid  of  iron  is  the  best 
preparation.  Young  children  absorb  codliver-oil  readily  when  given  by 
inunction.  The  oleate  of  mercury  may  be  combined  with  the  oil.  Good 
and  sufficient  nourishment  is  always  required,  but  the  child  should  not 
nurse  from  its  mother,  unless  it  is  positive  that  she  not  only  has  or  has  had 
syphilis,  but  is  in  fair  general  health.^     A  syphilitic  child  should  never  be 


^  While  the  author  does  not  believe  the  fetus  can  be  infected  with  syphilis  save 
through  the  medium  of  the  mother,  such  infection  has  been  asserted  by  good  authori- 
ties; hence  it  is  not  conservative  to  allow  a  syphilitic  child  to  be  nursed  by  an 
apparently-healthy  mother. 


468  CONGENITAL    AND   ACQUIKED    SYPHILIS    IN    CHILDREN. 

reared  by  a  nurse  who  has  not  had  syphilis.  In  general,  pure  cows'  milk 
is  best  for  the  child. 

When  the  child  is  nursed  by  its  .mother  or  by  a  wet-nurse  it  may  be 
treated  through  the  medium  of  the  breast-milk  by  the  administration  of 
potassie  iodid.  This  drug  is  eliminated  in  great  part  by  the  mammary 
glands,  which  physiologic  fact  is  of  great  therapeutic  service  in  hereditary 
syphilis.  From  5  to  10  grains  may  be  given  four  or  five  times  daily,  care 
being  exercised  in  regard  to  the  production  of  gastro-enteric  irritation  in 
both  mother  and  child. 

The  local  management  of  congenital  syphilis  is  often  of  importance. 
Perfect  cleanliness  is  a  paramount  indication.  Ulcers  and  excoriations 
should  be  kept  clean  and  dry,  and  dusted  with  calomel,  oxid  or  stearate  of 
zinc.  Condylomata  are  to  be  treated  as  in  the  adult,  but  with  milder  ap- 
plications. Ozena  requires  local  treatment,  and  a  nasal  douche  of  some  anti- 
septic solution  is  useful.  Seller's  tablets  and  the  preparation  known  as 
listerin  are  useful  for  this  purpose.  The  listerin  should  be  diluted  with 
about  3  or  4  parts  of  water,  and  used  three  times  daily.  Harsh  applications 
should  be  avoided  in  syphilitic  lesions  of  children,  as  their  delicate  skins  are 
very  intolerant  of  irritants  of  all  kinds.  In  all  cases  of  congenital  syphilis  the 
physician  should  warn  the  relatives  and  friends  of  the  danger  of  contagion. 
Failure  to  do  this  may  result  seriously,  as  is  illustrated  by  the  following 
case  of  the  author's: — 

Case. — A  young  man  contracted  syphilis  during  the  sixth  month  of  his  wife's 
first  pregnancy.  At  about  the  seventh  month  a  chancre  appeared  upon  her  right 
labium  minus,  and  shortly  after  her  child  was  born  characteristic  secondary  syphilis 
developed.  This  first  child  was  born  healthy,  a  fact  that  is  important  as  bearing  upon 
the  theory  that  the  child  escapes  infection  when  the  mother  is  not  syphilized  prior 
to  the  seventh  month  of  utero-gestation.  The  child  died  of  bronchitis  at  about  the 
age  of  two  years,  having  meanwhile  presented  no  evidences  of  syphilis.  Fifteen 
months  later  a  second  child  was  born  that  presented  positive  evidences  of  syphilis. 
This  child  died  in  about  three  weeks,  during  which  time  it  was  under  the  care  of  its 
grandmother  and  aunt.  These  benighted  females  caressed  and  fondled  the  infant 
incessantly,  the  family  physician  having  failed  to  apprise  them  of  the  danger  of 
infection.  Within  about  two  weeks  after  the  death  of  the  infant  both  ladies  developed 
labial  chancre  which  Avas  in  due  time  followed  by  secondary  syphilis.  As  a  final  com- 
plication of  the  infection  of  this  family,  the  grandmother  subsequently  infected  her 
husband.  Thus  the  infection  of  one  individual  was  responsible  for  the  syphilization 
of  five  persons.  Had  proper  caution  been  observed,  the  disease  might  at  least  have 
been  confined  to  the  syphilized  infant  and  its  parents. 


CHAPTER  XX. 

Teeatment  of  Syphilis. 

Constitutional  Treatment. — The  treatment  of  syphilis  can  be  in- 
telligently conducted  only  when  based  upon  a  clear  conception  of  the  patho- 
genesis of  the  infection  itself  and  the  lesions  produced  by  it  at  each  period 
of  the  disease.  There  is  room  for  great  difference  of  opinion  as  to  the  cor- 
rectness of  the  pathologic  views  set  forth  in  the  preceding  chapters,  yet  the 
author  believes  that  they  will  be  acknowledged  to  be  a  rational  foundation 
for  the  therapeusis  of  the  disease.  Errors  more  serious  in  their  effects  than 
the  disease  itself  are  often  committed  by  those  whose  treatment  of  syphilis 
is  not  founded  upon  a  rational  pathologic  basis. 

Mercury  in  Syphilis. — Syphilis  has  long  been  treated  upon  the  prin- 
ciple that  there  is  present  a  constitutional  poison  which  must  be  antidoted 
and  that  mercury  is  the  antidote.  Hutchinson  has  taught  that  this  drug 
has  the  property  of  neutralizing  the  specific  virus  upon  which  syphilis  is 
supposed  to  depend.  The  antidotal  theory  of  the  action  of  mercury  has 
been  accepted  by  some  of  our  best  syphilographers.  In  accepting  the  anti- 
dotal doctrine,  however,  they  have  seemed  to  consider  it  all-sufficient,  and 
have  failed  to  explain  the  physiologic  action  of  the  drug.  Mercury  has 
therefore  been  given  empirically:  i.e.,  solely  because  experience  has  proved 
it  to  be  curative  in  syphilis.  Now,  it  will  be  found  that  even  when  the 
system  has  been  completely  saturated  with  mercury,  perhaps  to  the  extent  of 
producing  severe  ptyalism,  the  disease  returns  directly  the  drug  is  with- 
drawn, thus  showing  that  the  syphilis  has  in  no  sense  been  antidoted.  On 
the  contrary,  the  case  is  usually  worse  than  ever.  On  the  other  hand,  we 
find  that  the  slow,  continuous,  and  moderate  use  of  mercury,  for  a  period 
corresponding  to  the  maximum  time  of  the  normal  duration  of  the  disease 
as  nearly  as  may  be,  and  without  at  any  time  producing  its  full  physiologic 
effects,  will  bring  about  a  cure  that  can  be  accomplished  in  no  other  way. 

It  is  well  known  that  mercury  has  the  power  of  inducing  fatty  degen- 
eration and  elimination  of  inflammatory  products,  or  "of  relieving  tissues 
encumbered  with  superfluous  and  obstructive  material."  This  condition  of 
the  tissues  is  precisely  what  exists  in  syphilis,  and  as  mercury  is  the  best 
remedy  at  our  command  for  the  correction  of  such  a  pathologic  state,  irre- 
spective of  etiology,  it  should  be  administered  throughout  the  natural  course 
of  the  disease,  not  to  antidote  a  poison,  but  to  remove  the  morbid  results 
produced  by  it,  as  fast  as  they  are  formed,  until  finally  the  syphilitic  im- 
pression upon  the  organism  has  naturally  exhausted  itself.  We  have  already 
seen  that  the  infection  of  syphilis,  whatever  its  material  substance,  prac- 
tically consists  in  the  influence  of  infection  on  healthy  cells,  causing  their 
rapid  proliferation  and  obstructive  accumulation.     That  the  peculiar  prop- 

(469) 


470  TEEATMENT    OF    SYPHILIS. 

erty  of  the  infection  is  due  to  a  pathogenic  microbe  of  as  yet  unknown 
form  is  probable;  but  whether  the  morbific  principle  be  a  germ,  virus,  or 
"degraded  cell/^  the  result  is  the  same.  It  is  a  rather  peculiar  fact  that 
every  method  of  treatment  for  syphilis  that  has  been  advocated  for  the  last 
two  or  three  centuries  has  comprised  such  measures  as  tend  to  produce  rapid 
tissue-change,  and,  more  especially,  elimination.  The  sweating  cure;  the 
use  of  hot  baths,  as  at  the  Hot  Springs  of  Arkansas;  the  purgation  and 
starvation  cures,  Boeck's  method  of  syphilization,  and  the  treatment  of 
pustulation  with  tartar  emetic,  all  of  which  have  been  recommended  by 
various  authorities  at  different  times,  are  chiefly  active  through  their  power 
of  inducing  fatty  changes  in  the  tissues.  In  the  various  methods  of  hydro- 
therapy the  benefit  is  secured  by  increasing  elimination.  This  is  especially 
important  in  view  of  the  toxins  elaborated  by  the  microbe  of  syphilis. 

The  action  of  mercury  upon  the  system  has  been  the  subject  of  con- 
siderable controversy,  particularly  as  regards  the  form  in  which  it  enters 
the  blood  and  its  modus  operandi  after  entering  the  system. 

Text-books  upon  materia  medica  and  therapeutics  are  notoriously  de- 
ficient in  their  presentation  of  the  subject  of  mercury  and  its  therapeutic 
uses  and  action.  Empiric  observation  appears  to  be  the  basis  of  most  of 
the  so-called  studies  of  the  drug.  Special  consideration  of  this  subject 
seems,  to  the  author,  to  be  singularly  appropriate  in  connection  with  the 
therapy  of  syphilis.  That  it  is  not  a  work  of  supererogation  is  well  shown 
by  the  statement  of  Bache: — 

Of  the  modus  operandi  of  mercury  we  know  nothing,  except  that  it  acts  through 
the  medium  of  the  circulation  and  that  it  possesses  a  peculiar  alterative  power  over 
the  vital  functions  which  enables  it  in  many  cases  to  subvert  diseased  actions.^ 

Such  rubbish  as  this,  while  it  may  reconcile  one  to  the  lucubrations 
of  theosophy,  merely  clogs  the  wheels  of  scientific  progress. 

The  most  logical  and  scientific  contribution  to  the  study  of  physiologic 
and  therapeutic  action  of  mercury  thus  far  made  is  the  series  of  essays  of 
S.  V.  Clevenger.2  The  author  takes  the  liberty  of  quoting  the  main  points 
made  in  Clevenger's  most  recent  paper  in  fulP: — 

Investigators  of  the  action  of  mercury  seem  to  have  been  lured  away  from 
evident  and  fundamental  principles  in  imagining  no  connection  between  the  easily- 
discernible  physical  properties  of  mercury  and  its  therapeutic  effects  and  assigning  the 
drug  occult,  catalytic  properties. 

Physiologists  do  not  disregard  the  mechanic  properties  of  water,  yet  mercury 
has   never   been   considered   from   this   stand-point.      Both   water    and   mercury   are 


^  "United  States  Dispensatory." 

^Chicago  Medical  Gazette,  February  20,  1880.  Chicago  Medical  Journal  and 
Examiner,  April,  1880.  American  Journal  of  Microscopy,  June  and  July,  1880. 
Chicago  Druggist,  1881.     Gaillard's  Medical  Journal,  March  17  and  24,  1881. 

^  "The  Mercurials,"  S.  V.  Clevenger,  Journal  of  the  American  Medical  Association, 
February  22  and  29,  1896. 


COXSTITUTIONAL    TEEATMEXT    OF    SYPHILIS.  4T1 

fluid  at  common  temperatures;  both  vaporize  at  all  temperatures;  both  change 
their  specific  gravities  in  passing  from  solid  to  fluid  and  thence  to  vapor;  both  main- 
tain extreme  division  of  their  particles  under  certain  circumstances,  and  by  loss  of 
heat  or  under  compression  cohere  in  drops  and  fall.  The  great  difi'erence  is  that 
mercury  is  fourteen  times  heavier  than  water  and  has  a  different  solidifying  point. 
1  claim  that  the  simple  mercurials,  such  as  pil.  hydrargyri,  unguentum  hydrargyri, 
hydrargj'rum  cum  creta,  emplastrum  ammoniaci  cum  hydrargyro,  emplastrum 
hydrargyri,  unguentum  hydrargyri  compositum,  linimentum  hydrargyri,  suppositoria 
hydrargyri,  and  the  oleate  of  mercury  depend  for  their  medicinal  properties  upon 
the  metal's  being  flnely  divided,  and  in  proportion  to  the  extent  to  Avhich  this 
division  is  carried  the  therapeutic  effects  of  the  drug  are  augmented.  A  grain  of 
mercury  undivided  may  have  no  physiologic  value,  but  when  separated  into  a  hundred 
thousand  globules  and  held  by  an  excipient  from  forming  large  particles,  as  in  blue 
mass,  the  well-known  effects  of  this  drug  are  obtained,  and,  the  more  potent  the 
pill,  the  greater  has  been  the  division  of  the  metal.  The  confections,  fats,  oils,  and 
other  substances  with  which  the  mercury  in  this  is  blended  by  the  pharmacist,  impart 
nothing  to  it  that  changes  its  character.  Though  occasional  oxidation  may  occur,  it 
will  be  seen  that  this  is  of  no  consequence  whatever.  My  experiments  prove  that 
mercury  undergoes  no  change  in  the  system  after  ingestion,  and  that  it  is  fully 
capable  of  producing  all  its  therapeutic  and  poisonous  effects  by  circulating  in  or 
obstructing  the  microscopic  channels  of  the  body. 

The  first  eight  mercurials  mentioned  above  contain  globules  of  the  metal  rang- 
ing from  one  five-hundredth  to  one  one-hundred-thousandth  of  an  inch  in  size,  mixed 
with  substances  more  or  less  inert.  The  first  numbers  one  hundred  thousand  globules 
and  upward  to  each  grain  of  mercury  in  the  mass;  the  second  is  much  more  finely 
divided;  the  third  is  badly  divided,  some  of  the  globules  being  quite  large,  as  the 
chalk  does  not  prevent  confluence,  and  it  is  therefore  an  unreliable  form  for  adminis- 
tration. The  "oleate"  contains  A^ery  minute  globules  reduced  by  the  oleic  acid  from 
the  yellow  oxid  with  which  it  is  incorporated.  The  metal  constantly  precipitates 
from  this  form  until  very  few  globules  are  suspended  in  the  oil.  The  other  mer- 
curials vary  more  widely  in  the  quantities  of  mercury  they  contain,  but  none  of 
them   convey   mercury  into   the   system   in  any   other   than   the   metallic   condition. 

No  other  metal  is  capable  of  comparison  with  mercury  in  its  mechanic  prop- 
erties and  physiologic  effects.  It  is  the  only  metal  fluid  at  common  temperature; 
it  resists  separation  into  smaller  masses  and  tends  to  form  larger  globules  when 
divided,  unless  held  apart  by  some  substance  that  will  coat  each  particle  separately. 
Each  minute  sphere  will  adapt  itself  to  the  shape  of  the  tubular  or  intercellular  space 
through  which  it  may  pass,  and  will  by  virtue  of  its  superior  gravitating  power 
cleanse  many  of  the  parts  through  which  it  circulates.  The  myriad  of  globules 
released  in  the  stomach  and  intestines  permeate  the  glandular  structures,  blood- 
vessels, and  lymphatics,  and  act  as  "alteratives,"  as  we  could  imagine  a  foreign  body, 
having  its  weight  and  adaptabilities,  would  act  when  introduced  into  circulating 
channels.  The  distances  between  the  globules  prevent  the  larger-sized  masses  from 
forming,  and  even  when  lying  compactly  an  albuminous  coating  will  effectually  pre- 
vent cohesion  until  such  covering  is  broken.  I  kept  for  a  month  a  mass  of  globules 
shaken  up  in  albumin,  and  found,  after  having  given  a  dose  to  a  frog,  that  the 
globules  maintained  their  sizes  in  the  tissues  of  the  animal,  and  that  but  few  had 
run  together  by  rupture  of  the  enveloping  albumin  in  the  stomach,  this  being  easily 
recognized  by  the  larger-sized  globules  and  the  silvery  luster  of  the  metal  which 
the  coating  had  previously  dimmed. 

No  one  disputes  the  fact  that  blue  mass  contains  minutely-divided  mercury, 
but  nowhere  have  I  found  any  opinion  as  to  the  probability  that  the  mercury  alone 
thus  given  produced  its  well-known  effects.     Histologic  tissues  and  a  flnelv-divided 


473  TREATMEXT  OF  SYPHILIS. 

metal  have  not  been  considered  as  amenable  to  mechanic  principles.  Both,  being 
microscopic,  are  at  once  relegated  to  mysterious  modes  of  working,  though  a  billionth 
of  an  inch  is  as  much  an  entity  as  a  billion  miles.  When  the  metal,  in  an  undivided 
or  uneombined  state,  is  administered,  it  rapidly  passes  through  the  intestines,  without 
any  apparent  affect.  The  cohesive  properties  of  its  component  particles  resist  sepa- 
ration. The  metal  must  be  well  triturated  with  an  excipient  to  reduce  it  to  globules; 
shaken  up  in  water,  a  temporary,  uneven,  yet  pretty-fine  division  may  be  made,  but 
the  water  opposes  only  very  temporary  resistance  to  the  metallic  confluence.  Honey, 
fats,  oils,  confections,  etc.,  when  mixed  with  the  fine  globules,  tend  to  keep  the  particles 
separate.     Albumin  and  glycerin  effect  a  separation  better  than  many  substances. 

Finely-divided  mercury  presents  a  grayish  appearance,  passing  into  black  as  the 
division  is  made  extreme,  this  condition  favoring  the  reverberations  of  light  from  par- 
ticle to  particle  until  no  rays  are  reflected  to  the  eye.  The  microscope  shows  that  no 
change  from  the  metallic  state  has  occurred  in  reducing  the  metal  to  this  form.  To 
count  the  globules  in  a  gram  (15.4  grains)  of  blue  mass  I  spread  it  mixed  with  water 
over  a  square  decimeter  of  surface  and  found  an  average  of  2000  visible  under  a  very 
low  magnifying  power  in  an  area  of  a  square  centimeter,  which  would  make  200,000 
of  these  globules  in  a  gram.  But  under  an  objective  magnifying  seventy  diameters 
more  than  ten  times  as  many  became  apparent.  The  size  of  these  globules  is  from 
one  six-thousandth  of  an  inch  to  sizes  almost  immeasurably  smaller.  In  a  gram 
of  pill  mass  there  is  '/a  of  a  gram  of  mercury,  which  would  cubically  measure  one- 
fortieth  of  a  cubic  centimeter.  Taking  0.01  millimeter  (Kolliker)  as  the  average 
diameter  of  the  capillaries,  the  division  of  this  mass  into  twenty-five  million  globules 
would  suffice  to  reduce  all  the  mercury  to  capillary  sizes.  But  all  are  not  so  reduced, 
though  many  are  divided  up  very  much  smaller.  Carpenter^  asserts  that  metallic 
mercury,  finely  divided,  can  be  absorbed  by  the  blood-vessels  from  the  alimentary 
canal.  If  these  minute  globules  drop  unchanged  into  the  glandular  tubules  and  force 
their  way  to  the  blind  extremities,  the  expulsion  of  less-heavy  contents  from  these 
tubules  would  occur  necessarily  Avithout  reference  to  whether  such  contents  were 
morbid  or  normal.  In  this  manner  a  deobstruent  action  is  obtained  by  as  simple 
and  effectual  means  as  by  cannon-balls  dropped  into  a  large  pipe.  Peristalsis  would 
assist  in  passing  the  same  globules  onward  to  other  secreting  and  excreting  surfaces, 
and  a  few  globules  of  the  proper  size  would  thus  change  the  conditions  of  a  large 
area  of  minute  tubules.  After  passing  the  pylorus  the  simple  follicles  and  duodenal 
glands  are  affected  as  were  the  gastric  tubules,  and,  by  thus  cleansing  glandular 
structure,  we  restore  normal  secretion,  or,  in  some  cases,  induce  hypersecretion.  The 
intestinal  villi  and  lacteals  pass  the  metal  into  the  circulation,  while  the  portal  vein 
carries  most  of  it  direct  to  the  hepatic  parenchyma.  Somewhat  as  the  direct  aortic 
connections  with  the  carotid  render  embolismus  most  frequent  in  the  left  cerebral 
artery,  the  peculiar  relationship  of  the  inferior  dental  arteries  with  the  external 
carotids  facilitates  mercury-accumulation  in  the  cancellated  tissue  of  the  inferior 
maxillary  bone,  with  resulting  tenderness  and  sponginess  of  gums.  The  minute 
globules  find  easier  ingress  to,  than  egress  from,  the  dependent  portion  of  the  lower 
jaw-bone,  where  they  accumulate  to  exert  a  slow,  but  sure,  disturbing  effect  upon 
the  gums  and  incisors,  and  finally  the  molars.  The  irritation  of  the  globules  upon 
the  peripheral  nerves  of  the  salivary  glands,  together  with  the  detersive  influence  of 
the  metal  itself,  already  mentioned,  accounts  for  the  activity  of  the  sublinguals,  sub- 
maxillary, and  parotid  glands  in  ptyalism.  The  question  arises:  why  does  not 
catharsis  continue  during  ptyalism  if  all  glandular  structures  are  affected,  the  liver 
being  caused  to  secrete  more  bile  as  the  maxillary  glands  are  stimulated  to  salivary 


'Physiology,"  p.  138. 


THE    ACTION    OF   MEECUKY    IN    SYPHILIS.       '  473 

excretion?  In  the  first  place,  the  innervation  of  all  glandular  structures  is  not  alike, 
hence  they  are  not  comparable  in  their  actions;  next,  ptyalism  succeeding  catharsis 
shows  that,  while  the  liver  and  intestines  evince  the  first  effects  of  mercurial  in- 
gestion, the  superior  glands,  are  reached  later  through  the  circulation.  From  this  it 
may  be  reasoned  that  mercurial  inunctions  impress  the  general  system  rather  than 
the  liver  or  alimentary  canal,  and  this  has  been  proved  clinically. 

Mercurials  load  the  circulation  and  emunctories  with  effete  matter  because  of 
their  deobstruent  effects  and  ability  to  insinuate  their  particles  among  all  tissues, 
separating  some  morbid  or  ulcerated  portions  from  the  healthy,  by  the  great  and 
universal  laAV  of  heavy  bodies  acting  in  the  line  of  "least  resistance."  If  the  bile  is 
improperly  diverted  or  suppressed,  it  restores  it,  by  opening  the  channels  through 
which  it  normally  flows;  if  superabundant  from  organic  obstruction  it  would  regulate 
its  quantity  in  the  same  way  by  affording  exit  for  morbific  causes.  Its  aplastic  action 
is  due  to  tiie  capillary  and  lymphatic  cleansing  it  produces,  the  million  minute 
globules  pushing  open  circulatory  channels  and  preventing  accumulation,  as  well  as 
affording  means  for  absorption.  Provisional  callus  and  wound-healing  is  interfered 
with  by  the  globules'  breaking  up  new  tissue  and  interfering  with  its  formation  as 
would  any  foreign  substance.  Mercury  has  been  distilled  over  in  considerable  quanti- 
ties from  the  bones  of  those  who  have  died  from  mercurial  cachexia,  the  little  par- 
ticles finding  stopping-places  in  the  cancellated  tissue  removed  from  more  active  cir- 
culatory influences,  and,  in  excess,  doubtless  dissecting  away  the  periosteum,  filling 
the  lacunse  and  canaliculi,  thus  producing  caries. 

Eld,  Buchner,  Cantu,  Jourda,  Anduoard,  Fourcroy,  Gmelin,  Byanon,  Mayengon, 
Bergeret,  Sakowsky,  Osterlin,  and  Heller  have  found  mercury,  regardless  of  the  form 
given,  in  the  blood,  urine,  serum  and  pus  of  ulcers,  saliva,  feces,  seminal  fluid,  and 
aborted  fetuses  of  salivated  women,  in  every  conceivable  secretion  and  in  every 
tissue.  Naunyn^  says:  "It  has  been  proved  by  good  observers  that  mercury  is  of 
relatively-frequent  occurrence  in  the  bones  in  quantities  readily  discernible  to  the 
naked  eye.  Years  after  mercurial  treatment  I  have  found  it  in  biliary  calculi.  .  .  . 
If  an  albuminate  be  formed  it  must  be  again  decomposed,  for  elimination  of  mercury 
sometimes  occurs  in  non-albuminous  urine,  while  albuminous  urine  sometimes  con- 
tains free  mercury.  Mercury  is  also  eliminated  by  the  bile,  saliva,  and  sweat.  In 
the  finest  globules,  it  is  to  be  found  in  the  bile,  urine,  and  feces  after  inunction." 

Taylor-  recovered  mercury-globules  from  the  brain  and  liver  which 
averaged  one-twenty-six-hundredth  of  an  inch,  while  those  recovered  from 
the  kidneys  were  still  larger.  As  he  states,  the  word  mercury  is  often  used 
in  a  loose  way  by  authors  to  include  the  salts  as  well.  In  most  cases  the 
usual  chemic  tests  were  evidently  applied  for  the  base,  and  the  radical  was 
undetermined.  The  microscope  would  have  been  effective  enough  for  the 
discovery  of  the  metal,  but  nowhere  does  any  use  appear  to  have  been  made 
of  this  instrument  in  these  investigations. 

Clevenger  claims  that  an  occasional  tonic  influence  of  the  metal  fol- 
lows wherever  glandular  obstruction  is  superinducing  diminution  of  the 
red  blood-corpuscles.  Mercury,  he  says,  is  not  a  tonic;  but — as  it  increases 
secretion,  removes  obstructions,  and  sets  the  corpuscular  manufactories  in 


"Ziemssen's  Cyclopedia,"  p.  615. 
"On  Poisons,"  p.  389.  --■ 


474  TREATMEXT    OF    SYPHILIS. 

order,  as  it  does  the  biliary — it  induces  tonicity.^  But  lie  further  says  that 
mercury  also  causes  anemia,  which  might  be  expected  from  persistence  in 
its  use,  when  its  occlusive  powers,  in  closing  the  minute  passages  and  tubular 
structures, — from  which,  in  medicinal  quantities,  it  removed  pre-existing 
obstructions, — are  remembered. 

Mercury  in  large  doses  diminishes  red  blood-corpuscles,  produces  anemia,  emaci- 
ation, ulceration,  and  febrile  symptoms,  witli  a  peculiar  "jerking,  thready"  pulse. 
Obviously  a  salutary  effect  upon  the  glandular  system,  wrought  by  small  doses,  be- 
comes pernicious  by  overdoses,  and  hematosis  is  seriously  disturbed  by  vascular 
stasis  induced  by  mercurial  plugging  of  the  arterioles  and  venules.  Any  irritation 
causing  perversion  of  the  hepatic  and  splenic  functions  is  certainly  followed  by 
hemic  degeneration,  and  the  pulse  characterizing  hydrargyria  is,  in  my  opinion,  due 
to  the  iiTegular,  but  frequent,  propulsion  of  blood  by  vis-a-tergo  clearing  of  the 
lesser  vessels  where  the  metallic  globules  had  for  awhile  backed  up  the  current 
till  forcibly  overcome.  This  leads  to  the  consideration  of  the  nervous  phenomena 
among  its  toxic  effects.  Mercury  produces  ulceration,  neuralgia,  paralysis  agitans, 
epilepsy,  often  melancholia,  all  of  which  can  be  produced  by  thrombus,  embolus, 
passive  or  active  cerebral  or  spinal  congestion,  or  resultant  anemia  directly  wrought 
in  the  way  mentioned. 

Take  any  treatise  on  nervous  diseases,  and  wherever  the  words  clot,  thrombus, 
and  embolus  occur,  substitute  mercurial  accumulation,  and  the  cause,  in  my  opinion, 
is  fully  explained.  Accumulation  in  the  terminal  twigs  of  the  cerebral  cortical 
arteries  would  induce  paralysis,  paresis,  softenings,  tremors,  hemiopia,  amblyopia, 
etc.,  according  to  location,  and  whether  the  basilar  or  carotid  supply  contained  the 
larger  quantity  of  mercury.  Should  the  middle  cerebral  artery  be  the  meeting-place 
of  the  molecules,  according  to  subsequent  arrival  of  the  metal  thence,  aphasia,  hemi- 
plegia, or  anesthesia  will  supei-A'ene,  singly  or  together,  depending  upon  whether  the 
gyrus  operculum,  insula,  optic  thalamus,  corpus  striatum,  crus,  or  internal  capsule 
had  become  congested  or  deprived  of  blood  by  this  interference. 

Bumstead  relates  a  case  of  epilepsy  as  due  to  syphilitic  neurosis,  which  can  be 
better  accounted  for  as  mercurialization.-  The  patient  had  been  subjected  to  a  long 
coiu-se  of  mercury,  and  manifested  neuropsychoses  quite  compatible  Avith  the  sup- 
position that  the  taercury  was  their  cause.  Bumstead  gave  more  mercury  with 
iodid  of  potassium  and  was  gratified  by  immediate  benefit.  The  iodid  alone  would 
have  been  the  better  remedy,  as  iodin  unites  directly  with  mercury  to  form  mer- 
curous  iodid.  That  mercuric  iodid  is  not  formed  is  evident  from  absence  of  the 
physiologic  effects  of  this  active  compound.  The  less  soluble  mercurous  iodid  is 
carried  back  into  the  circulation  from  the  bony  or  vascular  recesses  in  which  the 
iodin  united  with  the  mercury,  and,  decomposing,  leaves  the  mercury  to  reproduce 
the  same  phenomena  as  when  first  ingested,  with  the  advantage  that  the  excretory 
channels  have  a  better  chance  to  eliminate  the  mercury  while  circulating  than 
when  lying  dormant  in  inaccessible  places.  This  explains  why  the  iodids  resalivate 
the  mercurialized. 

Finding  the  metallic  mercury  "in  every  conceivable  tissue  and  fluid  of  the 
body"  warrants  the  supposition  that  diabetes,  vomiting,  gastric  and  pulmonary  irri- 


^  This  is  begging  the  question  somewhat.  If  mercury  produces  "tonicity"  it  is 
truly  a  tonic,  irrespective  of  its  modus  operandi. 

^  This  assertion  of  Clevenger's  is  open  to  doubt.  The  epilepsy  may  have  been 
due  to  syphilitic  toxins.  The  toxemic  theory  has  even  been  advanced  as  explaining 
ordinary  epilepsy. 


THE    ACTIOlSr    OF   MEECUEY    IX    SYPHILIS.  475 

tation  following  hydrargic  exhibition  are  owed  to  nerve-center  irritation,  meclianic 
and  direct,  in  the  floor  of  the  fourth  ventricle,  or  to  interference  with  its  blood- 
supply.  At  this  stage  an  augmentation  of  the  salivary  flow  by  irritation  of  the 
chorda-tympani  nerve  might  also  be  expected,  and  this  may  be  among  the  initiatory 
sialagogic  causes.  This  irritation  is  exerted  upon  the  nerve-centers  by  the  heavy 
globules  of  the  metal,  exactly  as  serous  or  purulent  accumulations  are  mechanically 
productive  of  nervous  and  mental  derangements,  or  that  mercurial  interference  with 
the  circulation  thereabouts  would  be  followed  by  such  neuroses. 

The  elimination  of  mercury  from  the  system  seems  to  be  principally  through 
the  kidneys;  but  gold  rings,  brooches,  or  necklaces,  in  contact  with  the  person,  will 
become  covered  with  mercury-films  during  a  course  of  hydrargic  treatment.^  Con- 
sistently with  its  vaporizable  tendency  increasing  with  heat-elevation,  warm  baths 
help  its  passage  through  the  sudoriparous  channels,  and  it  is  well  known  that  nearer 
the  tropics  greater  immunity  is  enjoyed  from  the  effects  of  large  doses. 

Clevenger  directs  attention  to  the  harmony  of  the  mechanic  view  of 
the  action  of  mercury  with  the  pathology  of  the  disease  as  presented  by 
Otis,  Biiumler,  and  Wagner  and  adopted  in  the  preceding  chapters  of  this 
work.  Baumler  formulated  the  pathologic  principle  npon  which  Otis  based 
his  entire  teaching  of  syphilitic  phenomena,  when  he  supported  the  view 
that  the  characteristic  feature  of  the  active  syphilitic  cell  is  the  possession 
of  ability  to  set  up  in  other  cells,  through  contact,  its  own  disposition  to 
rapid  proliferation.-  These  cells  not  only  obstruct  tissues,  especially  lym- 
phatic structures,  but  they  undergo  degeneration  and  elimination.  Otis 
has  especially  insisted  that  the  syphilitic  tubercle,  in  common  with  all 
syphilitic  sequels,  is  a  deposit  of  arrested  normal  material,  the  favorite  seats 
of  which,  according  to  Baumler  and  Wagner,  are  in  the  subcutaneous  cellu- 
lar tissue,  the  skin,  in  and  upon  the  bones,  the  liver,  the  testicles,  brain, 
kidneys,  and  infiltrations — of  microscopic  size — scattered  through  the 
parenchyma  of  an  organ.  The  cause  of  the  accumulations,  Rindfleisch 
claims,  is  interference  with  the  lymphatic  circulation;  the  natural  channel 
through  which  the  nutritive  material  exuded  into  the  tissues  in  excess  of 
the  necessities  of  growth  and  repair  is  returned  to  the  general  circulation.^ 
This  point  has  been  sufficiently  expatiated  upon,  and  is  reverted  to  in  this 
connection  simply  to  show  how  beautifully  Clevenger's  researches  harmonize 
with  the  pathologic  doctrines  of  syphilis  advanced  in  the  preceding  chap- 
ters. The  newer  points  brought  out  by  Clevenger  in  his  most  recent  paper 
are  of  absorbing  interest.  His  theory  that  mercury  exerts  a  phagocytic  action 
in  syphilis  is  most  fascinating,  and  harmonizes  perfectly  with  the  microbial 
hypothesis  of  syphilitic  pathogenesis. 


^  Clevenger  evidently  ignores  the  fact  that  this  is  due,  in  cases  where  inunction 
treatment  is  used,  largely  to  the  mercurial  A-apov  arising  from  the  skin.  It  occurs, 
however,  where  the  drug  is  only  given  int-ernally.  This  clearly  demonstrates  elimina- 
tion by  the  skin. 

^  "Ziemssen's  Encyclopedia." 

^  Rindfleisch. 


476  TEEATMEXT  OF  SYPHILIS. 

Reverting  to  the  observation  that  mercury  attaches  to  itself  fine  particles  of 
dust  that  are  with  difficulty  separated  therefrom,  the  behavior  of  the  metallic 
globules  in  the  physiologic  channels  may  be  justifiably  compared  to  that  of  phago- 
cytes. If  a  micro-organism  is  eventually  established  as  the  cause  of  syphilis,  the 
antagonism  of  mercury  for  the  disease  may  be  found  not  only  in  its  assisting  elimi- 
nation generally,  but  through  phagocytic  action  of  the  globules  in  enveloping  the 
morbific  organism,  as  the  wandering  cells  of  the  circulation  are  known  to  load 
themselves  with  bacteria,  micrococci,  etc.  In  this  manner  the  adjacent  tissues  would 
be  kept  from  infection  and  the  globules  of  mercuiy  could  carry  away,  through  the 
emunctories  generally,  the  microscopic  cause  of  syphilis. 

Clevenger  holds  that  all  the  evidence  thus  far  obtainable  goes  to  show 
that  the  therapeutic  action  of  mercur}^  is,  in  the  main,  mechanic.  As 
water  enters  and  issues  from  hydrants  unchanged,  so  mercury  enters  the 
Ijody  and  leaves  it  jDlainly  as  mercury;  and  yet  speculation  has  been  rife 
as  to  some  undemonstrable  chemic  change  occurring  in  transit,  notwith- 
standing that  the  bodies  of  mercurialized  animals  have  been  repeatedly 
opened  and  mercury  found  in  the  various  organs  en  route  toward  excretion 
or  dormant  in  the  tissues.  Salivation  occurs  through  accumulation  of  the 
metal  in  the  terminals  of  the  dental  arteries  by  gravitation  to  the  most 
dependent  portions  of  the  jaw.  Accumulation  in  the  cancellated  tissue, 
gums,  and  salivary  glands  would  fully  account  for  ptyalism,  the  earliest 
effects  being  manifest  in  the  lower  incisors — most  apt,  from  their  position, 
to  be  affected.  Fournier  claims  that  mercurial  ulcerations  are  situated  al- 
wa3^s  on  the  edges  of  the  tongue,  and  on  the  side  on  which  the  person 
has  been  accustomed  to  lie  when  sleeping.  This  supports  the  theory  of 
the  gravitating  tendency  of  the  globules.  It  must  be  remembered,  how- 
ever, that  the  gravitation  of  the  tongue  itself  down  upon  the  teeth,  where 
it  remains  for  some  hours,  may  have  much  to  do  with  the  localization  of 
mercurial  ulcers  of  the  tongue.  Another  point  is  the  gravitation  of  irri- 
tating fluids  to  the  edge  of  the  tongue,  which  remains  bathed  in  them  for 
hours  at  a  time. 

The  pivotal  point  in  Clevenger's  theory  of  the  action  of  mercury,  as 
demonstrated  by  his  exceedingly-interesting  experiments,  is  the  conclusion 
that  all  the  mercuric  and  mercurous  preparations  decompose  in  the  body 
into  mercury-globules  the  sizes  of  which  determine  much  of  their  effects. 
The  experiments  Avith  blue  mass  may  be  accepted  as  the  standard  demonstra- 
tion of  the  mechanic  action  of  mercury.  Clevenger  first  placed  the  web  of  a 
normal  frog's  foot  under  a  ^/^  inch  objective,  magnifying  seventy-five 
diameters.  He  thus  acquainted  himself  as  thoroughly  as  possible  with  the 
peculiarities  of  its  blood-vessels,  pigment-granules,  and  appearances  by  re- 
flected and  transmitted  light.  He  then  gave  the  frog  5  grains  of  blue  mass. 
Twenty-four  hours  afterward  the  frog  was  examined  and  little  globules  of 
mercury  were  found  mingled  with  the  mucus  secreted  by  its  skin.  These 
were  brushed  off  and  its  feet  again  placed  under  the  lens.  The  blood-vessels 
Avere  found  to  be  choked  with  metallic  mercury.    Aneurismal  and  varicose 


THE    ACTION    OF    MEECUKY    IN    SYPHILIS.  477 

pouches  were  distended  with  mercurj-,  and  a  great  number  of  the  so-called 
pigment-granules  had  changed  to  a  yelloW;,  metallic  luster;  these  spots 
reflected  the  light  as  would  mercury,  when  examined  by  direct  rays.  As 
many  as  twenty  of  these  lacunse,  or  star-shaped  bodies,  could  be  counted 
between  two  toes,  and  altogether  there  were  about  a  hundred  on  each  foot. 
The  close  resemblance  between  the  lacunse  thus  injected  and  Strieker's 
description  of  the  lymphatic  sacs  in  the  course  of  the  lymphatics  of  the  frog 
led  Clevenger  to  believe  that  he  had  observed  mercury  in  the  lymphatic 
channels  of  the  frog.  Two  little  tubules  choked  with  mercury  presented  a 
singular  phenomenon.  Under  the  power  used  the  tubes  appeared  blind,  but 
a  little  globule  of  unmistakable  mercury  lay  upon  the  surface  of  the  web  at 
the  outer  end  of  one  of  the  tubes.  Watching  this  globule  intently  for  ten 
minutes,  it  suddenly  increased  in  size,  and  the  tube  collapsed,  having 
emptied  its  mercurial  contents  outward.  The  globule  thus  formed  was  twice 
as  large  as  the  characteristic  blue-mass  globule,  and  was  easily  removed  from 
the  web  by  a  camel's-hair  pencil.  The  other  similar  tube  was  more  curved, 
and  at  its  outer  end  had  two  such  globules,  both  of  which  increased  slowly  in 
size,  and  in  half  an  hour  had  grown  very  large  at  the  expense  of  the  tubular 
contents,  the  tube  disappearing  as  did  the  first  mentioned.  Nowhere  could 
anything  like  foreign  particles  circulating  in  the  blood  be  seen.  The  white 
and  red  blood-corpuscles  were  distinctly  visible,  but  in  one  capillary  was  a 
small  dark  particle  gradually  accumulating  similar  particles  near  it;  these 
were  apparently  minute  mercury-globules;  they  accumulated  against  the 
current,  and  the  blood  passed  around  them  freely;  suddenly  the  down- 
stream end  of  the  mass  broke  away  and  apparently  washed  away  in  the 
blood  out  of  sight.  This  was  repeated  several  times  while  the  mass,  in  this 
way,  Avas  proceeding  up  stream.  In  one  vein  a  large  globule  of  mercury 
lying  motionless  could  be  plainly  seen,  while  the  blood-corpuscles  changed 
positions  to  pass  by  it  in  the  vessel,  which  they  did  as  rapidly  as  ever. 
Some  of  the  exuded  mercury-globules  on  the  web  furnished  good  compara- 
tive measurements.  Six  globules  together  measured  the  diameter  of  a  small 
capillary,  and  could  easily  have  passed  through  this  blood-vessel  abreast. 
The  experiment  was  repeated  on  a  smaller  frog  by  anointing  the  chin, 
•  axillge,  and  thorax  with  oleate  of  mercury,  with  the  same  result.  To  a 
large  frog  was  given  10  grains  of  blue  mass  and  as  much  blue  ointment. 
Twenty-four  hours  later  the  lymphatic  sacs  were  engorged,  but  the  blood 
circiilation  was  undisturbed.  In  all  the  frogs  so  treated,  where  unavoidable 
lacerations  of  their  feet  occurred  in  manipulating,  there  oozed  from  the 
torn  edges  minute  globules  of  mercury.  The  last  frog  shed  his  skin  in 
three  days  after  the  dose,  but  otherwise  none  of  them  underwent  any  ap- 
parent change  in  health  or  vigor.  The  skin  must  have  afforded  the  main 
means  of  exit  for  the  metal.  There  was  not  a  fragment,  however  small,  of 
this  discarded  cuticle  that  did  not  exhibit  plainly  the  metallic  globules. 
Dissecting  the  frog  last  mentioned,  the  stomach  was  found  coated  with  the 


478  TEEATMEXT    OF    SYPHILIS. 

globules;  but  ten  days  having  elapsed  since  the  dose,  no  mercury  was  found 
between  the  intestines  and  the  skin  except  in  the  derma,  and  probably  in 
the  liver.  This  organ  was  apparently  choked  with  sacculations  of  an  opaque 
substance,  which  proved  to  be  aggregations  of  metallic  mercury  in  the 
hepatic  channels. 

In  the  hope  of  discovering  the  course  of  the  metal  through  the  frog's 
body,  a  gram  of  finely-divided  mercury,  in  albumin,  was  given  to  a  male 
frog.  In  five  hours  globules  appeared  on  its  back.  Dissection  showed 
that  the  intestines,  renal  and  portal  circulation,  heart,  kidneys,  and  even 
the  testes  contained  numerous  globules  of  mercury,  and  the  lymphatic 
passages  were  beautifully  injected  with  globules  much  more  finely  divided. 
Apparently  the  lymph-channels  had  chosen  the  lesser  particles,  or  the  metal 
had  undergone  further  division  in  absorption  into  the  passages. 

Experiments  with  calomel  and  other  preparations  of  mercury  have 
shown,  according  to  Clevenger,  that  all  preparations  of  mercury  are  reduced 
to  a  finely-divided  metallic  form  before  entering  the  system.  The  pancreatic 
fluid  has  a  marked  action  in  reducing  calomel  to  the  metallic  state. 

Clevenger  touches  upon  one  very  important  point  in  the  clinical  use 
of  calomel  in  the  following  words: — 

From  remote  periods  it  has  been  supposed  that  salt  and  acids  converted  calomel 
into  corrosive  sublimate  in  the  stomach,  though  this  has  been  repeatedly  shown 
not  to  be  the  case.  One  of  the  denials  was  made  from  numerous  experiments  by 
Verne^:  "No  poisonous  compounds  are  generated  from  calomel  in  combination  with 
such  bodies  as  salt,  sugar,  citric  acid,  etc.;  and  whenever  such  mixtures  have  been 
followed  by  alarming  symptoms  the  calomel  must  have  been  an  impure  article.  The 
protochlorid  of  mercury  is  really  a  more  stable  compound  than  ordinarily  considered, 
and  it  would  appear  that  bichlorid  is  more  easily  converted  into  the  proto  combina- 
tion rather  than  vice  versa." 

Upon  testing  the  stocks  of  calomel  in  a  dozen  drug-stores  in  Chicago  I  found 
corrosive-sublimate  traces  in  nearly  all,  and  in  that  of  a  few  manufacturers  the 
amount  to  the  ordinary  dose  must  have  rendered  this  chlorid  far  from  "mild."  So, 
as  Verne  notes,  when  calomel  acts  harshly  it  is  probable  that  it  is  impure  by  contain- 
ing the  bichlorid. 

Further,  as  to  the  mistake  that  a  higher  salt  may  be  formed  from  a  lower 
mercurous  compound,  Wurtz-  says:  "Bichlorid  of  mercury  is  easily  reduced  to  the 
monochlorid  or  even  the  metallic  state  by  many  agents.  Light  will  precipitate  calomel 
from  an  aqueous  solution,  and  many  organic  substances  reduce  the  bichlorid  to  calomel 
or  even  to  quicksilver,  especially  under  the  influence  of  light."  In  the  face  of  these 
facts  it  can  hardly  be  logically  maintained  that  calomel  shows  a  tendency  to  assume 
a  higher  state  of  oxidization.  It  also  appears  absurd  to  prohibit  the  consumption  of 
acidulous  food  Avhile  administering  calomel,  the  more  so  when  we  consider  the 
presence  of  free  hydrochloric  acid  in  the  stomach,  and  remember  that  this  acid  reacts 
with  calomel  only  at  a  boiling  temperature. 

The   author   considers   the   foregoing   argument   based   upon    chemic 


^  "Repertoire  de  Pharmacie,"  June,  1879. 
^  "Dictionnaire  de  Chimie." 


THE   ACTION    OF    MEKCUKY    IN    SYPHILIS.  479 

facts,  as  convincing  enough  regarding  the  chemistry  of  calomel,  but  as  a 
matter  of  clinical  observation  it  is  unsafe  to  base  our  practice  upon  such 
deductions.  It  is  possible  that  the  speedy  occurrence  of  salivation  after  the 
administration  of  calomel  and  acids  in  succession  is  due  to  impurity  of  the 
mercurial,  and  is  a  mere  coincidence,  so  far  as  the  acid  is  concerned;  but  such 
accidents  occur  so  often  that  we  are  not  justified  in  assuming  such  a  skep- 
tic position  in  practice.  It  by  no  means  follows  that  calomel  is  not  reduced 
by  ingested  acids  in  the  gastro-intestinal  tract,  even  though  such  reduction 
does  not  take  place  outside  the  body.  Chemic  evidence  to  the  contrary  not- 
withstanding, the  author  would  advise  a  conservative  course:  i.e.,  abstinence 
from  acids  while  taking  mercurials.  The  general  conclusions  arrived  at 
from  his  observations  are  recapitulated  by  Clevenger  as  follows: — 

1.  Mercury  acts  mechanically  as  a  deobstruent  upon  the  glands  and  lesser 
tubular  structures,  by  virtue  of  its  unstable  chemic  properties,  its  volatility,  and 
great  weight. 

2.  Its  condition  in  the  fluids  and  tissues  is  that  of  finely-divided  globules  of  the 
metal  numbering  upward  of  one  billion  to  the  cubic  centimeter,  and  as  vapor  of  the 
metal.  In  whatsoever  form  it  may  be  taken,  it  is  quickly  precipitated  as  mercury, 
and  without  change  is  excreted  or  retained  in  the  system,  mainly  in  the  bones. 

3.  It  cleanses  the  intimate  visceral  tissues  by  projecting  from  them  materials  of 
less  weight,  and  in  this  way  breaks  up,  removes,  or  prevents  morbid  accumulations. 
In  excess  it  occludes  the  tubular  parts,  and  may  produce  any  of  the  phenomena 
attending  stasis  of  vital  operation  anywhere  about  the  body,  such  as  ulceration,  con- 
gestion, paralysis,  anemia,  etc. 

4.  The  liver  and  inferior  maxillary  region — for  anatomic,  and  the  former  for 
physiologic,  reasons — receive  most  of  its  primary  influences. 

5.  It  can  be  given  in  larger  doses  in  warm  weather  or  climates  because  heat 
favors  its  elimination,  systemic  efl'ects  decreasing  necessarily  in  proportion. 

6.  Its  antiphlogistic  properties  are  merely  deobstruent  and  detergent. 

7.  Its  value  in  syphilis  is  owed  to  its  acting  in  the  line  of  least  resistance,  break- 
ing up  any  nidns  the  disease  may  form.  The  ability  of  the  metal  to  envelop  and 
carry  micro-organisms  gives  it  an  ameboid  or  phagocytic  value.  In  phagedenic  ulcer- 
ative processes  it  would  be  contra-indicated,  because  the  degeneration  is  too  rapid 
to  be  effectually  reached  by  mercury,  which  is  not  the  case  in  slower-forming  specific 
ulcerative  stages.  Its  administration  in  these  diseases  could  be  regulated  by  the 
rapidity  of  degradative  processes.  Comparatively  slowly  acting  morbid  centers  or 
those  of  a  congested  nature  could  be  improved  by  mercury  where  the  drug  would 
only  accelerate  rapid  tissue-destruction. 

8.  It  is  tonic,  by  increasing  red  blood-globules  whose  formation  has  been  pre- 
vented by  glandular  perversion,  the  metal  removing  the  obstructions  toward  their 
formation,  while  in  overdoses  anemia  is  produced  by  occluding  the  vessels  it,  in  small 
doses,  cleansed. 

9.  The  solubility  and  consequently  superior  penetrating  power  of  the  bichlorid  is 
probably  productive  of  characteristic  merciu'ial  effects  which  seem  out  of  propor- 
tion to  the  amount  of  metal  in  doses  of  this  salt;  but  it  is  not  to  be  denied  that 
chemic  or  direct  neurotic  influences  co-operate  with  the  metal  in  the  more  active 
preparations,  and  thus  possess  features  of  their  own. 

10.  Experimental  evidence  is  opposed  to  the  probable  formation  of  any  compound 
in  the  body,  and  supports  the  belief  that  decomposition  invariably  and  almost  in- 


480'  TEEATMEXT    OF    SYPHILIS. 

stantaneously  follows  its  ingestion,  with  the  j)recipitation  of  mercury  as  minutely- 
divided  globules  from  any  preparation  of  which  it  fonns  the  base. 

A  careful  survey  of  Clevenger's  experiments  cannot  fail  to  impress 
one  with  their  conscientiousness  and,  in  general,  with  the  logic  of  his  con- 
clusions. In  order  to  demonstrate  that  mercury  acts  only  mechanically, 
however,  it  would  he  necessary  hy  experiment  on  animals  to  show  that  all 
of  the  mercury  introduced  into  the  system  can  be  collected  again  in  the 
metallic  form  from  the  animars  secretions,  excretions,  and  tissues.  This 
condition  is,  of  course,  difficult  of  fulfillment.  Again,  it  is  questionable 
whether  mercury  in  so  fine  a  state  of  subdivision  as  is  demonstrated  by 
Clevenger  would  not  be  subjected  to  a  certain  amount  of  chemic  change  in 
the  tissues.  The  potency  of  bioehemism  is  an  unknown  quantity,  and  may 
be  a  much  more  important  factor  in  the  physiologic  action  of  mercury  than 
Clevenger  seems  to  believe.  The  author  freely  admits,  however,  that  the 
mechanic  action  of  the  metal  is  paramount,  and  that  it  alone  seems  sus- 
ceptible of  experimental  proof. 

The  authors  view  that  mercury  acts,  to  a  certain  extent,  in  the  form 
of  varying  chemic  compounds  of  a  more  or  less  soluble  character,  is  sub- 
stantiated by  the  fact  that  mercury  is  eliminated  in  its  non-metallic  form 
by  the  kidneys,  and  may  be  separated  from  the  urine  in  the  form  of  a  sulphid 
by  proper  tests. 

Admitting  the  mechanic  action  of  mercury,  the  author  is  inclined  to 
believe  that  the  drug  acts  to  a  certain  extent  by  blocking  up  the  capillaries 
supplying  the  areas  affected  by  syphilitic  infiltration.  The  syphilitic  neo- 
plasm being  of  low  vitality,  it  takes  but  little  to  enhance  its  innutrition  and 
produce  fatty  degeneration — in  sort,  to  hasten  the  normal  process  of  reso- 
lution and  elimination.  This  condition  the  mercury  furnishes  by  im- 
peding blood-supply.  The  ferret-like  action  of  the  drug  in  driving  mor- 
bific material  before  it  perhaps  comes  into  play  later,  when  the  neoplasm 
has  undergone  softening  and  is  ready  for  elimination.  Under  such  circum- 
stances the  minute  mercury-globules  probably  act  by  pushing  the  degenerate 
cell-material  before  them  into  the  various  eliminative  areas  of  the  body, 
where  the  morbific  matter  is  expelled,  along  with  the  free  mercury.  A 
moment's  thought  is  sufficient  to  impress  the  importance  of  this  deobstruent 
action  upon  the  mind  of  one  familiar  with  the  pathology  of  syphilis  as  pre- 
sented in  this  work. 

One  criticism  that  the  author  would  make  upon  Clevenger's  views  is 
that  he  does  not  lay  sufficient  stress  upon  the  circulatory  vis  a  tergo  in 
explaining  the  career  of  mercury  in  the  blood  and  tissues.  Obviously,  such 
pliable,  plastic,  fine  globules  as  those  of  metallic  mercury  can  penetrate  and 
traverse  the  finest  capillaries.  This,  in  fact,  occurs,  and  the  blood-power 
behind  them  drives  them  on  and  on,  until  some  obstruction  is  encountered. 
This  obstruction  is  furnished  (1)  by  the  lymphatic  tissues,  (2)  by  neoplastic 


EFFECTS    OF   MEECURY   UPON    THE    BLOOD.  481 

formations,  (3)  b}'  adventitious  connective-tissue  organization,  (4)  by  com- 
Ijressed  or  contracted  blood-vessels,  and  (5)  by  gravitation,  which  specially 
tends  to  cause  its  accumulation  in  certain  localities. 

The  relative  importance  of  the  hearths  action,  the  elasticity  and  con- 
tractility of  the  arteries,  muscular  contraction,  and  the  aspirating  power  of 
the  chest  are  obviously  the  same  with  respect  to  propelling  mercury  through 
the  tissues  as  in  the  physiologic  propulsion  of  the  blood-corpuscles. 

Effects  of  Mercury  upon  the  Blood. — The  action  of  mercury  upon  hema- 
topoiesis  is  a  most  important  point  for  consideration  in  the  therapeusis  of 
syphilis.  The  action  of  mercury  upon  the  blood  is  of  great  practical  interest, 
inasmuch  as  by  its  use  diametrically-opposite  effects  may  be  produced,  ac- 
cording to:  (1)  the  dose  used,  (2)  the  duration  of  its  administration,  (3)  the 
constitutional  condition  of  the  patient,  and  (4)  the  stage  of  the  disease. 

Knowledge  of  the  varying  effects  of  the  drug  upon  the  blood  is  of  so 
great  importance  that  the  physician  who  does  not  understand  them  is  hardly 
to  be  trusted  with  the  management  of  syphilis.  Every  practitioner  worthy 
of  the  name  is  familiar  with  the  variations  in  the  effect  of  mercury  upon  the 
gastro-intestinal  tract.  That  large  single  doses  will  act  as  a  cathartic,  and 
moderate  doses  as  a  laxative,  is  as  familiar  as  the  fact  that  by  small  and  fre- 
quently-repeated doses,  for  from  twenty-four  to  thirty-six  hours,  severe 
stomatitis  and  ptyalism  may  be  produced.  If  the  drug  be  given  in  a  less 
vigorous  fashion  for  a  longer  period,  pallor  and  debility  may  result,  due  to 
depreciation  in  the  quantity  and  quality  of  the  red  blood-corpuscles,  de- 
fibrination of  the  blood-plasma,  and  increased  tissue-waste.  A  certain  degree 
of  these  effects  is  unavoidable  in  the  treatment  of  syphilis;  but  it  should  be 
our  chief  aim  to  keep  them  within  bounds  and  thus  avoid  the  danger  of  pro- 
ducing permanently-injurious  effects.  Such  effects  as  great  pallor,  wasting, 
and  debility,  pustular  or  vesicular  eruptions,  with  fever  known  as  "mercurial 
fever"  and  marked  tremors,  may  result  from  the  action  of  mercury,  and 
that  too,  without  the  occurrence  of  ptyalism.  On  the  other  hand,  small 
doses  of  mercury,  in  various  cachectic  or  anemic  conditions,  particularly 
during  the  sequels  of  syphilis,  stimulate  hematogenesis  and  rapidly  and 
markedly  increase  the  quantity,  while  improving  the  quality  of  the  red 
corpuscles  and  fibrin,  thus  lessening  hydremia.  This  statement  is  supported 
by  the  experiments  of  Keyes  with  the  hemometer,  and,  moreover,  by  clin- 
ical observation  of  the  action  of  the  drug.  The  question  of  the  possible 
accumulation  and  prolonged  retention  of  mercury  in  the  system  has  been 
considered  to  be  suh  judice,  the  weight  of  opinion  being  in  favor  of  the  view 
that  proofs  of  such  a  result  of  the  drug  are  wanting.  The  author  has  not 
yet  seen  any  bugaboo  cases  in  which  portions  of  bone  are  found  to  be  "full 
of  metallic  mercury."  That  metallic  mercury  may  be  found  in  the  tissues 
during  a  prolonged  and  thorough  course  of  the  drug  is  true,  but  that  such 
a  condition  prevails  for  years  after  the  treatment  is  not  so  certain.  Alleged 
cases  of  this  character  have  probably  been  under  more  recent  mercurial 


483  TREATMENT  OF  SYPHILIS. 

treatment  than  they  acknowledge  or  perhaps  are  aware.     They  may  have 
been  innocently  taking  medicines  of  mercurial  composition.^ 

In  a  series  of  elaborate  experiments  Schuster,  of  Aix-la-Cliapelle,  has 
shown  that  elimination  of  mercury  by  the  feces  is  by  no  means  inconsider- 
able.^ The  method  of  administration  was  by  inunction.  Some  of  his  con- 
elusions  are  of  interest: — 

1.  Elimination  of  mercury  by  the  feces  is  regular  and  continuous. 

2.  Elimination  after  thirty  to  forty-five  days'  mercurial  inunction  is  complete 
in  six  months. 

3.  Consequently^  persistence  of  mercury  in  the  organism  cannot  occur. 

This  conclusion  is  important  as  bearing  upon  the  cumulative  action  of 
mercur}^,  but  is  obviously  fallacious. 

lodin  in  Syphilis. — There  is  another  remedy  that  experience  has  shown 
to  be  curative  in  syphilis,  and  which  is  second  onl}^  to  mercury.  lodin,  in 
the  form  of  the  iodids,  especial^,  is  invaluable, — in  fact,  well-nigh  in- 
dispensable,— more  particularly  in  late  syphilis.  The  iodids — of  which 
potassic  iodid  is  the  type — act  in  two  ways  in  the  cure  of, syphilis,  viz.: 
firstly,  by  their  own  intrinsic  power  of  producing  fatty  degeneration  and 
elimination  of  morbid  products,  especially  toxins;  and,  secondly,  by  liberat- 
ing, exciting  to  renewed  activit}',  and  eliminating  the  mercur}^  that  is  stored 
up  in  the  tissues,  thus  assisting  its  action.  It  is  evident  that  the  first  of  these 
effects  is  the  most  important,  for  the  iodids  have  a  most  powerful  effect  in 
resolving  the  products  of  inflammatory  changes,  or  of  adventitious  deposits, 
irrespective  of  their  cause.  This  in  the  face  of  the  argument  that  iodin  can 
cure  syphilis  only  by  liberating  mercury  from  the  tissues,  and  that  it  is 
the  mercur}^,  and  not  the  iodids,  that  produces  the  curative  effects.  That 
this  is  incorrect  is  shown  by  the  beneficial  effects  of  potassic  iodid  in  cases 
of  late  syphilis  in  which  mercury  has  never  been  administered.^ 

When  to  begin  Treatment.- — Having  decided  upon  the  administration  of 
mercury  in  the  constitutional  management  of  syphilis,  when  shall  we  begin 
its  use?  It  is  claimed  by  some  that  it  is  not  good  practice  to  begin  treat- 
ment until  secondary  symptoms  develop,  until,  in  short,  the  case  is  ma- 
tured, as  mercury  will  have  little  effect  prior  to  that  time.  It  is  the  au- 
thor's opinion,  however,  that  it  is  our  duty  to  begin  treatment  just  as  soon 
as  the  diagnosis  is  established,  as  the  duration  of  the  initial  lesion  is  thereby 
shortened,  and  secondar}'  sj'^mptoms  moderated,  if  not  prevented.     To  save 


^  ClcA^enger  quotes  the  instance  of  a  cadaver  exhibited  at  an  eclectic  college,  the 
skin  of  which  was  full  of  mercury-globules.  As  Clevenger  did  not  himself  see  the 
cadaver,  the  ease  is  by  no  means  proved. 

^  Journal  of  Cutaneous  and  Venereal  Diseases,  September,  1883. 

^  In  the  British  and  Foreign  Medical  Review  for  October,  1845,  Hassing,  of  Copen- 
hagen, reported  195  cases  of  syphilis,  70  of  which  were  cured  by  potassic  iodid  alone, 
without  using  mercury  at  any  stage.  These  experiments  have  since  been  frequently 
repeated  by  various  observers,  with  like  results. 


SELECTION    OF    MEKCUEIALS.  483 

the  patient  from  lesions  npon  the  body  or  face,  that  he  who  runs  may  read, 
is  very  desirable,  and  is  only  to  be  accomplished  by  early  treatment.  It 
must  be  acknowledged,  however,  that  those  cases  in  which  treatment  is  not 
begnn  until  pronounced  eruptions  appear  sometimes  seem  to  respond  more 
readil}^  and  to  give  rather  less  annoyance  during  the  active  period  than 
where  mercury  is  given  as  soon  as  chancre  develops.  Whether  the  prospect 
of  a  permanent  cure  is  brighter  is  questionable.  Dumesnil  opposes  very 
strongly  the  practice  of  giving  mercurials  before  secondary  eruptions  ap- 
pear, no  matter  how  plainly  marked  the  case.^  The  difficulty  of  diagnosis 
is  one  of  the  most  powerful  arguments  advanced  by  him,  and  is  presented 
so  clearly  and  forcibly  that  one  can  hardly  offer  a  criticism.  There  are, 
however,  many  cases  that  are  so  plainly  marked  that  this  argument  falls  to 
the  ground.  In  quite  a  proportion  of  cases  the  diagnosis  is  doubtful  and 
the  conscientious  physician  must  necessarily  wait.  Kegarding  such  dubious 
cases,  there  should  be  no  difference  of  opinion.  Dumesnil  further  claims 
that  by  the  administration  of  mercury  secondar}^  symptoms  are  not  pre- 
vented, but  are  mereh^  delayed.  This  statement  is  rather  too  sweeping.  It 
is  true  that  secondary  symptoms  are  rarely  prevented  entirely,  but  is  not 
their  severity  usually  markedly  moderated?  What  is  to  be  said,  moreover, 
respecting  those  cases  in  which  no  symptoms  whatever  follow  the  primary 
sore  until,  perhaps  years  after  the  disease  was  forgotten,  severe  sequels  ap- 
pear? According  to  Dumesnil,  the  non-appearance — or  apparent  non-ap- 
pearance— of  secondary  symptoms  would  indicate  that  in  such  cases  syph- 
ilis did  not  exist.  In  some  cases  secondary  symptoms  are  ven^  slight  and 
likely  to  be  overlooked  by  the  patient.  In  such  cases  the  necessity  for  con- 
stitutional treatment  might  be  first  announced  by  severe  sequels  at  a  period 
too  late  to  warrant  a  hojDC  for  a  permanent  cure.  The  author  believes  that 
in  doubtful  cases  delay,  as  suggested  by  Fournier,  is  most  proper,  but,  on 
the  other  hand,  holds  that,  whenever  an  unequivocal  diagnosis  of  syphilis 
has  been  made,  treatment  should  be  begun  at  once. 

Selection  of  Mercurials. — Having  determined  upon  the  administration 
of  mercury,  it  remains  to  select  an  eligible  preparation.  The  mildest  and 
least  irritating  form  of  the  drug  is  the  mercurous  iodid,  or,  as  it  is  some- 
times termed,  the  green  or  protiodid.  It  is  best  given  in  pill  form,  in  doses 
of,  on  the  average,  ^/-  grain,  thrice  daily.  This  dose  is  to  be  continued  for 
several  days,  and  then  increased  one  pill  per  day — still  in  divided  doses — 
until  the  gums  become  somewhat  tender  or  the  stomach  and  bowels  are  dis- 
turbed. The  author  generally  gives  the  drug  until  the  gums  are  slightly 
affected,  and  then  gradually  lessens  the  dose  until  the  patient  is  taking  about 
half  the  amount  necessary  to  produce  slight  physiologic  effects.  This,  as 
Keyes  terms  it,  is  the  patient's  average  dose,  and  is  usually  from  two  to  four 


^  "When  to  Begin  the  Treatment  of  Syphilis,"  A.  H.  0.  Dumesnil,  St.  Louis  Med- 
ical and  Surgical  Journal,  August,  1883. 


484  TEEATMEiS^T    OF    SYPHILIS. 

pills,  of  the  strength  mentioned,  daily.  This  should  generally  be  continued 
— with  certain  intervals  of  rest — throughout  the  course  of  treatment.  It  is 
often  well  to  substitute  from  time  to  time  some  of  the  other  mercurials  for 
the  mercurous  iodid.  It  is  well  to  bear  in  mind  the  possibility  of  injurious 
effects  from  the  cumulative  action  of  the  drug,  and  also  the  fact  that  it  is 
likely  to  lose  its  effect  upon  the  disease  after  a  time.  The  author's  plan  is  to 
omit  the  mercurous  iodid  at  intervals  of  two  to  three  months,  and  give  potas-. 
sic  iodid  pretty  freely  for  about  four  weeks.  In  this  way  any  mercury  that 
may  be  stored  up  in  the  tissues  is  liberated,  rendered  active,  and  eliminated. 
The  system  is  again  susceptible  to  its  action  by  the  time  the  pills  are  re- 
sumed. In  addition,  the  special  action  of  iodin  is  obtained.  By  proceed- 
ing in  this  manner  the  possibility  of  injuring  the  patient  with  mercury 
is  practically  avoided.  There  are  various  other  eligible  forms  of  mercury. 
The  bic3i'anid  has  been  known  to  agree  when  no  other  preparations  could 
be  tolerated.  Clevenger  alludes  to  the  eligibility  of  this  salt  when  others 
produce  gastric  irritation.^  The  red  iodid  has  been  especially  recommended 
in  the  late  scaly  eruptions.  Its  superior  merit,  however,  is  not  obvious.  A 
well-known  preparation,  called  Zittman's  decoction,  was  formerly  much  used 
in  Germany.  It  contains  mercury  in  combination  with  sarsaparilla  and 
aromatics. 

It  is  often  a  matter  of  great  difficulty  to  induce  patients  to  take  med- 
icine for  a  sufficient  length  of  time  to  effect  a  cure.  They  are  prone  to 
find  fault  with  the  physician  if  he  is  honest  with  them,  and  suspect  him 
of  sordid  motives  if  he  attempts  to  coerce  them  into  prolonged  treatment. 
It  is  a  peculiar  fact  that  most  people  try  desperately  to  compel  the  physician 
to  be  dishonest  with  them  in  self-defense.  They  misinterpret  honesty  as 
lack  of  skill,  and  will  more  readily  pay  the  quack  huge  fees  for  false  prom- 
ises and  blatant  pretenses  than  the  scientific  physician  a  moderate  amount 
for  skillful  treatment.  They  have  always  at  their  tongue's  end  a  long  list 
of  their  friends  who  were  cured  of  a  bad  case  of  syphilis  (?)  by  Dr.  So- 
and-So  in  three  months.  In  spite  of  this  perverseness  of  human  nature, 
however,  it  is  the  jDhysician's  duty  to  tell  his  patient  that  if  he  wishes  to 
get  well  he  must  take  medicine  for  at  least  three  years,  and  if  any  doubt 
exists  at  the  end  of  that  time  he  had  best  add  another  year,  especially  if  he 
has  matrimonial  intentions.  As  already  stated,  no  syphilitic  patient  should 
be  permitted  to  marry  under  three  years  from  the  appearance  of  the  chan- 
cre.   In  the  case  of  women  a  still  longer  period  is  advisable. 

Another  difficult  item  in  the  management  of  most  cases  of  syphilis  is 
convincing  the  patient  that  it  is  absolutely  necessary  for  him  to  avoid  the 
use  of  liquor  and  tobacco  for  an  extended  period,  and  that  he  must  abstain 
from  the  various  dissipations  and  excesses  to  which  he  has  been  accustomed. 
This  point  must  be  insisted  upon,  however,  and,  with  good  conduct  upon 


S.  V.  Clevenger,  op.  cit. 


TKEATMEXT  OF  SYPHILIS.  485 

the  part  of  the  patient  assured,  half  the  battle  will  have  been  gained.  The 
late  Willard  Parker  used  to  say  to  his  syphilitic  patients:  "Yon  are  pos- 
sessed of  three  devils, — rum,  tobacco,  and  syphilis.  If  you  will  rid  your- 
self of  the  two  former,  I  will  rid  you  of  the  latter." 

Some  patients  do  not  tolerate  mercury  well,  diarrhea  or  gastric  dis- 
turbance following  the  slightest  attempt  at  pushing  the  drug.  In  this  event, 
^/s  grain  of  extract  of  hyoscyamus  should  be  added  to  each  pill.  Another 
good  plan  is  to  give  the  patient  a  few  10-grain  powders  of  bismuth  sub- 
nitrate,  with  instructions  to  take  one  whenever  the  stomach  or  bowels  be- 
come troublesome.  In  other  cases  the  patient  tolerates  a  large  amount  of 
mercury.  The  author  has  repeatedly  given  several  grains  of  the  protiodid 
daily  for  some  weeks,  without  affecting  the  gums  or  digestive  tract  in  the 
slightest  degree.  In  such  eases  the  large  dose  should  be  kept  up  for  a  few 
weeks,  and  then  diminished  to  about  four  or  five  pills  daily.  In  some  cases 
the  pil.  duo.  introduced  by  Bumstead  is  an  excellent  preparation,  especially 
if  the  patient  is  anemic  and  debilitated.  The  pil.  duo.  contains  gr.  ij  of  pil. 
hydrarg.  and  gr.  j  of  ferri  sulph.  exsiccat.  It  should  be  given  precisely  like 
the  mercurous  iodid.  It  usually  produces  constipation;  hence  an  occasional 
dose  of  Apenta,  Hunyadi,  or  Friederichshalle  water  may  be  necessary. 

When  a  patient  fails  to  respond  readily  to  the  internal  administration 
of  mercury,  or  when  gastro-intestinal  irritation  is  marked,  the  drug  may  be 
used  by  inunction.  Were  it  not  for  its  uncleanly  features,  this  method 
would  be  best  of  all.  It  certainly  is  the  most  useful  method  for  a  short, 
relatively  vigorous  course  of  treatment.  The  oleate — a  minute  subdivision 
of  mercury  in  oleic  acid — is  the  best  preparation,  although  too  expensive 
for  some  patients.  A  5-  to  10-per-cent.  solution  should  be  used,  and  about 
5]  rubbed  into  the  axillse,  morning  and  night.  As  the  axilla  become  irri- 
tated, the  rubbing  may  be  done  at  the  flexures  of  the  joints,  where  the  skin 
is  thin  and  absorption  readily  occurs.  The  mercurial  ointment,  though  less 
elegant,  may  be  used  as  a  substitute  for  the  oleate.  It  may  be  rubbed  in 
or  spread  upon  a  white  flannel  band  kept  in  contact  with  the  abdomen,  the 
band  being  shifted  about  occasionally  and  the  skin  kept  clean  by  daily 
washing.  Another  good  plan  in  hospital  practice  is  to  rub  the  ointment 
upon  the  soles  of  the  feet  and  have  the  patient  wear  heavy  woolen  socks. 

In  some  cases  mercurial  inunctions  or  mercury-vapor  baths  must  be 
wholly  depended  upon,  and  it  may  be  said,  in  this  connection,  that  both  are 
very  efficacious  in  obstinate  skin-lesions.  The  general  dissemination  of 
mercurous  vapors  over  the  surface  of  the  body  explains,  in  great  part,  the 
beneficial  action  of  the  inunction  method. 

A  simple  method  of  giving  a  mercurial  bath  is  as  follows:  A  small 
tin  plate  supported  by  a  tripod,  an  alcohol-lamp,  and  a  pan  of  boiling  water 
are  all  the  necessaries.  The  patient,  being  stripped,  seats  himself  in  a  cane- 
bottomed  chair  and  wraps  the  chair  and  his  body  thoroughly  in  blankets. 
About  20  grains  of  the  mercurous  chlorid  is  placed  upon  the  plate,  the  lamp 


486  TEEATMEXT  OF  SYPHILIS. 

is  lighted,  and  the  whole  ajjparatns  placed  under  the  chair.  In  a  few 
minutes  the  calomel  is  vaporized,  and,  with  the  steam  from  the  boiling 
water,  is  deposited  upon  the  skin  of  the  patient.  In  fifteen  minutes  the 
lamp  may  be  extinguished,  and  after  ten  minutes  more  the  patient  should 
wrap  himself  in  a  dry  blanket  and  go  to  bed.  In  the  morning  he  may 
rub  himself  with-  dry  towels,  the  mercury  having  become,  in  great  part, 
absorbed.  About  three  baths  jDer  week  are  necessary.  Calomel  is  the  best 
jDreparation  for  fumigation,  because  of  its  freedom  from  irritating  proper- 
ties and  the  readiness  with  which  it  volatilizes  without  reduction  to  the 
metallic  condition.  The  red  oxid  also  volatilizes  readily,  but  its  fumes  are 
more  irritating  to  the  respiratory  tract. 

It  is  sometimes  necessary  to  bring  a  patient  under  the  influence  of 
mercury  very  rapidly:  e.g.,  in  cases  of  syphilitic  iritis,  in  which  a  few  hours' 
delay  might  be  fatal  to  the  integrity  of  the  eyes.  In  such  an  event  calomel, 
in  doses  of  ^/^o  grain  every  hour,  will  accomplish  the  desired  result;  and, 
if  necessary,  ptyalism  can  be  produced  in  this  manner  within  twenty-four 
to  forty-eight  hours.  Another  rapid  and  eflficacious  method  of  introduction 
of  mercury  is  b}^  Lewin's  method  of  hypodermic  injection.^  From  ^/m  to  ^/g 
grain  of  mercury  bichlorid,  in  combination  with  ^/^^  grain  of  morphin  and  a 
small  quantity  of  sodium  chlorid,  is  dissolved  in  15  minims  of  distilled 
water,  and  injected  into  the  cellular  tissue,  preferably  of  the  buttock,^  once 
or  twice  daily;  a  minute  dose  of  cocain  may  be  advantageously  combined 
with  the  injection.  There  is  a  vast  difference  in  the  susceptibility  of  differ- 
ent patients  to  these  injections.  The  author  has  never  seen  an  abscess  pro- 
duced by  them,  but  some  patients  complain  bitterly  of  the  pain  following 
their  administration.  In  others,  hard  and  painful  indurations  follow  their 
use.  If  the  precaution  is  taken,  however,  of  introducing  the  needle  well 
into  the  cellular  tissue  before  injecting  the  fluid,  very  little  trouble  will 
be  caused  in  the  majority  of  cases.  It  is  probably  the  best  treatment  for 
syphilis,  in  a  certain  proportion  of  cases  where  the  patient  can  be  induced 
to  attend  strictly  to  treatment.  As  an  adjunct  to  internal  treatment,  mild 
injections  are  excellent.  There  is  one  point  to  which  the  author  especially 
desires  to  call  attention,  viz.:  the  bichlorid  makes  the  needle  very  brittle, 
and,  unless  it  is  frequently  changed,  it  may  break  off  in  the  tissues,  an 
accident  that  the  patient  is  quite  likely  to  criticise.  For  the  average  patient 
in  the  hands  of  the  general  practitioner,  Lewin's  method  is  inferior  to  the 
internal  use  of  the  mild  iodid.  Abadie  urges  the  advantages  of  his  method 
of  subcutaneous  injections  of  mercuric  bichlorid  in  the  late  ocular  lesions  of 
acquired  syphilis  and  constitutional  S3'philis: — 


^Lewin,  "Behandlung  der  Syphilis,  mit  Subcutaner  Sublimat-injection."'  Berlin, 
1869. 

-Stern  (Progres  Medical,  Paris,  1878)  expresses  a  preference  for  injecting  the 
tissues  of  the  back. 


TREATMENT  OF  SYPHILIS.  487 

These  lesions  are  characterized  by  their  complex  nature  and  the  slowness  of 
their  evolution.  Chororetinitis  is  frequently  accompanied  by  chronic  iritis,  and  even 
by  parenchymatous  keratitis.  Many  of  these  cases  heal  spontaneously  without  treat- 
ment, Avhile  others  show  a  very  disquieting  tenacity,  Avhich  resists  all  treatment  until 
the  hypodermic  mercurial  injections  are  employed.  This  latter  method  of  treatment 
also  gives  good  results  in  certain  forms  of  chororetinitis  limited  to  the  region  of 
the  macula.  In  cases  of  isolated  paralysis  of  the  cranial  nerves  or  twigs  of  nerves, 
without  cerebral  complications,  the  extreme  rebelliousness  of  the  trouble  is  success- 
fully conquered  by  the  hypodermic  method  of  treatment.  For  this  purpose  I  employ 
a  solution  of  mercuric  chlorid,  1  part;  sodic  chlorid,  2  parts;  and  distilled  water, 
100  parts.  I  inject  20  drops  of  the  solution  beneath  the  skin  of  the  back  on  alternate 
days,  and  make  gentle  massage  over  the  spot  afterward.^ 

An  interesting  method  is  the  treatment  of  syphilis  by  intramnscnlar 
injections  of  mercnry.  Mr.  J.  Astley  Bloxam  states  that  over  fifteen  hun- 
dred patients  were  treated  by  this  method  at  the  Lock  Hospital  and  else- 
where dnring  eighteen  months^  with  the  best  results. 

The  solution  for  injection  contains  6  grains  of  the  bichlorid  to  the  ounce  of 
distilled  water,  and  of  this  20  drops  constitute  a  dose.  The  sore  generally  begins  to 
heal  very  promptly  after  one  or  two  injections,  the  secondary  symptoms  are  markedly 
modified,  and  after  a  course  of  treatment  extending  over  a  year,  more  or  less,  the 
patient  is  enabled  to  discontinue  his  attendance.  Toward  the  latter  end  of  the  course 
of  treatment  the  injections  may  be  given  less  frequently,  and,  as  a  general  rule,  not 
more  than  from  8  to  12  grains  of  the  perchlorid  are  injected  in  all.  It  is  undesirable 
to  repeat  the  injections  oftener  than  once  a  week,  as  otherwise  salivation  might  be 
induced,  and  the  quantity  injected  each  time  (Va  grain)  is  found  to  be  quite  suffi- 
cient until  the  next  time.  There  are  several  advantages  attending  this  method  of 
exhibiting  mercury.  In  the  first  instance,  it  is  only  necessary  to  see  the  patient  once 
a  w^eek,  when  sufficient  mercury  is  injected  to  last  until  the  following  week;  secondly, 
salivation  is  not  produced,  as  is  apt  to  happen  when  the  patient  continues  to  take 
mercury  for  a  whole  week  while  away  from  the  supervision  of  his  medical  attendant; 
thirdly,  the  gastric  derangements  that  are  so  apt  to  follow  the  administration  of 
mercury  by  the  mouth  are  by  this  means  avoided;  lastly,  the  ease  and  certainty  of 
administration  which  enable  the  surgeon  to  do  his  own  dispensing  with  a  minimum 
of  trouble.  A  little  quinin  is  generally  given  during  the  course  as  a  tonic,  but  no 
other  form  of  mercury  is  administered.  The  injections  are  made  preferably  deep  into 
the  muscular  mass  of  the  glutei.  The  pain  following  is  slight  and  soon  passes  away, 
and  there  is  no  danger  of  abscess.- 

Hypodermic  injections  of  calomel  as  originally  recommended  by  Sca- 
renzio  and  Eicordi,  over  thirty  years  ago,  have  been  highly  extolled  by 
numerous  writers.  It  is  asserted  that  the  insoluble  salt  is  slowly  transformed 
by  the  alkaline  juices  of  the  tissues  and  the  blood  into  the  soluble  mer- 
curic chlorid.  From  1  to  3  grains  may  be  given  suspended  in  aseptic 
albolene  or  glycerin,  twice  weekly.  Taylor  advises  a  mixture  of  calomel 
and  sodic  chlorid,  5  parts  of  each,  suspended  in  50  parts  of  distilled  water. 
Of  this  fluid  an  ordinary  hypodermic  svringeful  may  be  injected  every 

^  Abadie,  Annales  d'Oculistique,  May,  June,  1886. 
=  New  York  Medical  Journal,  October  23,  1886. 


TEEATMENT    OF    SYPHILIS. 

eight  or  ten  days.^  The  sides  of  the  buttocks  and  the  back  beneath  the 
shonlder-blades  are  the  best  sites  for  the  injections.  Care  should  be  taken 
to  have  both  skin  and  syringe  aseptic.  The  needle  should  be  larger  than 
the  ordinary  hypodermic  variety. 

The  calomel  injections  are  often  painful,  and  sometimes  followed  by 
painful  swellings  and  abscesses — despite  all  care.  Their  field  of  usefulness, 
therefore,  comprises  emergency  cases  onlj^,  as  a  rule.  For  routine  use  they 
are  hardly  satisfactory. 

In  the  case  of  females  with  very  weak  stomachs,  and  in  children,  the 
gray  powder  or  hydrarg.  cum  creta  is  an  excellent  mercurial  preparation. 
If  it  becomes  necessary  to  push  the  mercurial,  it  should  be  done  by  super- 
adding fumigations  or  inunctions,  rather  than  by  increasing  the  internal 
dose.  A  preparation  highly  lauded  abroad  is  the  tannate  of  mercury; — 
hydrargyrum  tannatum  oxydulatum, — which  is  justly  claimed  to  be  perfectly 
unirritating.  The  hydrargyrum  formidatum  is  also  serviceable.  The  pep- 
tonate  is  another  fanciful  preparation  used  by  our  French  confreres. 

UxTOWARD  Effects  of  the  Mercurials. — Many  of  the  disagreeable 
and  injurious  effects  observed  from  the  action  of  mercurj''  are  due  to  the  tend- 
ency upon  the  part  of  most  teachers  of  therapeutics  to  dwell  only  upon  the 
good  effects  that  result,  or  are  supposed  to  result,  from  the  administration  of 
various  drugs.  A  certain  amount  of  discussion  is  usually  given  of  the  im- 
mediate or  remote  toxic  effects  of  the  drugs  per  se.  The  relation  of  the 
method  of  administration  and  the  disease  conditions  under  which  the  drug 
is  given  to  its  untoward  effects  are  insufficiently  considered.  Although 
confessedly  a  champion  of  the  mercurial  treatment  in  syphilis,  the  author 
is  fully  aware  that  many  evil  effects  are  liable  to  attend  its  administration 
where  due  consideration  is  not  accorded  its  intrinsic  toxic  qualities.  The 
reputation  of  mercury  as  a  remedy  has  been  injured  chiefly  at  the  hands  of 
inexperienced  and  careless  practitioners — ^more  especially  those  who  have 
treated  syphilis  upon  the  antidotal  principle.  Much  of  the  popular  preju- 
dice against  mercury  has  resulted  from  observation  of  patients  treated  by 
this  class  of  practitioners.  We  meet  with  a  decided  and,  it  must  be  con- 
fessed, fairly  well-grounded  prejudice  against  the  use  of  mercury  existing 
in  the  minds  of  the  laity,  the  principal  reason  for  which  has  just  been  stated. 
It  is  a  self-evident  fact  that  many  of  the  alleged  evil  results  of  mercury 
are  due  to  the  circumstance  that  its  use  has  not  been  faithfully  persisted 
in  for  a  sufficient  length  of  time;  but,  notwithstanding  this,  there  is  un- 
doubtedly a  certain  proportion  of  cases  in  which  serious  injury  to  the  sys- 
tem of  the  patient  may  be  justly  attributed  to  the  drug  itself.  With  proper 
care,  however,  the  author  ventures  to  assert  that  there  is  no  drug  that  is 
safer  or  more  reliable,  and  he  has  yet  to  see  a  single  case  of  permanent  in- 
jury resulting  from  the  drug  when  properly  used. 


^  "The  Venereal  Diseases/'  E.  W.  Taylor. 


UNTOWARD    EFFECTS    OF    MERCUEY.  489 

Mercurial  Depression. — Cases  are  occasionally  met  with  in  which  mer- 
cury has  a  yery  unsalutary  effect  upon  the  patient,  in  the  form  of  intense 
mental  and  emotional  depression,  even  when  very  moderate  doses  are  given. 
In  such  cases  it  may  be  necessary  to  give  tonics  and  even  stimulants,  in  order 
to  counteract  this  condition.  Or  it  may  even  he  necessary  to  stop  the  mer- 
cury entirely,  and  depend  upon  potassic  iodid.  Coca-wine  or  fluid  extract 
and  quinin  will  be  found  useful  in  such  cases. 

Ptyalism. — One  of  the  most  frequent  of  the  injurious  elfeets  produced 
by  mercury  is  ptyalism.  Salivation  in  any  marked  degree  is  always  injuri- 
ous, and  no  more  pronounced  effect  should  ever  be  produced  than  a  slight 
increase  in  the  salivary  secretion,  a  coppery  taste  in  the  mouth,  a  slightly- 
bluish  tint  at  the  margin  of  the  gums,  and — what  is  often  a  good  indication 
to  diminish  the  amount  of  mercury — a  sensation  as  if  the  teeth  were  too 
long.  This  latter  symptom  is  of  especial  value.  Ptyalism  may  go  on  to 
acute  stomatitis.  Ulceration  of  the  cheeks  or  gums  sometimes  occurs  with- 
out previous  salivation;  but  this  is  quite  rare.  To  prevent  these  annoyances, 
the  mouth  and  teeth  ought  to  be  put  in  perfect  order  by  the  dentist,  prior 
to  beginning  treatment.  Tartar  should  be  removed  and  the  teeth  cleaned, 
and  all  those  that  are  decayed  either  extracted  or  filled. 

The  causes  of  salivation  are  idiosyncrasy  or  excretory  inactivity  with 
moderate  doses  of  mercury  or  large  doses  without  idiosyncrasy.  Diseases  of 
the  mouth  and  gums  predispose  to  it,  and  sometimes  exposure  to  cold  and 
wet  during  a  mercurial  course  will  bring  it  on.  The  elimination  of  mercury 
from  the  system  being  chiefly  through  the  medium  of  the  bowels,  skin,  sali- 
vary glands,  and,  in  slight  amount,  the  kidneys,  ptyalism  and  other  cumu- 
lative evil  effects  of  the  drug  may  be  best  guarded  against  by  the  adminis- 
tration of  diuretics,  laxatives,  and  the  use  of  hot  baths.  Ptyalism  is  not 
likely  to  occur  so  long  as  the  eliminative  areas  are  not  inhibited  in  the  per- 
formance of  their  functions. 

The  dicta  of  various  authorities  regarding  the  channels  by  which 
mercury  is  eliminated  from  the  body  appear  to  the  author  to  be  very  unre- 
liable. It  has  been  so  often  asserted  that  mercury  is  chiefly  eliminated  by 
the  kidneys  that  the  profession  has  taken  it  for  granted,  and  writers  upon 
therapeutics  and  materia  medica  have  gone  on  repeating  the  mistaken 
notions  of  our  medical  forefathers,  much  to  the  disadvantage  of  scientific 
therapeutics.  The  experiments  related  in  so  important  a  work  as  Blyth, 
on  "Poisons,"  are  as  vague  as  possible.  For  example,  after  asserting  that 
the  main  channel  by  which  absorbed  mercury  passes  out  of  tlie  body  is  the 
kidneys,  Blyth  substantiates  his  claim  by  quoting  from  Bynssen,  who — after 
experimenting  with  mercuric  chlorid — -came  to  the  conclusion  that  "it  could 
be  detected  in  the  urine  in  about  two  hours,  and  in  the  saliva  about  four 
hours  after  its  administration."  Bynssen  considered  that  elimination  was 
complete  in  twenty-four  hours. 

The  amount  of  mercuric  chlorid  given  is  stated,  but  nothing  is  said 


490  TEEATMEXT  OF  SYPHILIS. 

about  the  quantity  recovered  nor  the  form  in  which  it  appeared.  It  was 
recovered  as  a  sulphid,  but  the  form  in  which  it  existed  in  the  urine  was 
undetermined.  That  a  certain  amount  of  mercury  is  discoverable  in  the 
urine  during  the  administration  of  that  drug  is  probably  true.  It  is  hardly 
possible  that  so  many  experimenters  as  have  investigated  this  subject  could 
have  been  deceived.  So  far  as  the  treatment  of  syphilis  is  concerned,  the 
mercuric  chlorid — the  most  soluble  form  and  therefore  the  form  that  is 
most  likely  to  be  eliminated  by  the  kidneys — is  exceptionally  given.  The 
mercurous  iodid,  mercurous  chlorid,  tannate  and  hydrarg.  cum  creta,  and 
ung.  hydrarg.,  convey  mercury  into  the  system  in  a  form  that  is  eliminated 
chiefly  by  the  bowel,  the  kidney  playing  a  secondary  and  minor  role.  As 
already  intimated,  the  presence  of  mercury  in  the  urine  in  any  other  than 
the  metallic  form  shows  conclusively  that  Clevenger's  theory,  while  prob- 
ably in  the  main  correct,  is,  as  already  intimated  by  the  author,  insufficient 
to  explain  the  jDhysiologic  action  of  mercury  entirely.  If  mercury  Avere 
eliminated  in  the  metallic  form  in  the  urine  to  any  extent,  it  would  accumu- 
late in  greater  or  less  amount  in  the  bottom  of  the  bladder,  or  in  any  vessel 
into  which  the  urine  might  be  ejected.  Its  presence  in  the  urine  in  soluble 
form  shows  that  it  acts  upon  the  system  chemically  as  well  as  mechanically. 
Potassic  iodid  assists  in  the  elimination  of  mercury,  chiefly  through  its 
deobstruent  action  upon  the  tissues  and  by  increasing  secretion  and  excre- 
tion. Exposure  to  cold  and  wet  during  a  mercurial  course  causes  ptyalism, 
through  the  reflex  hyperemia  and  consequent  inhibition  of  function  of  the 
eliminative  areas  incident  to  cold-taking. 

Treatment  of  Ptyalism.- — Obviously,  the  first  step  is  to  stop  the  mer- 
curial. Potassic  chlorate  may  be  given  internally,  and  a  mouth-wash  used, 
composed  of  potassic  chlorid  and  tincture  of  myrrh,  in  the  proportion  of 
5ij  of  the  potassic  chlorid  and  .^ss  of  tincture  of  myrrh  to  ^iiiss  of  water. 
Glycerin  may  be  added  if  desired.  The  chlorid  of  potassium,  and  not  the 
chlorate,  should  be  specified  in  this  mixture.  In  some  severe  cases  of  sali- 
vation the  patient  cannot  swalloAv  solid  food,  and,  whether  this  be  the  case 
or  not,  fluid  aliment  is -indicated.  As  already  noted,  the  skin,  kidneys,  and 
more  particularly  the  bowels  require  attention.  The  kidneys  may  be  assisted 
in  the  performance  of  their  function  by  Turkish  baths  and  Jaborandi.  Chlo- 
rate of  potassium  in  doses  of  10  grains  every  three  hours  is  very  useful.  The 
kidneys  should  be  flushed  by  copious  draughts  of  hot  water  in  combination 
with  potassic  citrate.  It  is  not  wise  to  give  potassic  iodid  at  first,  as  it  may 
enhance  the  difficulty  by  liberating  and  making  active  any  mercury  that 
has  become  stored  up  in  the  system.  As  the  case  improves  the  iodids  may 
be  given  with  great  benefit.  A  single  case  of  mercurial  salivation  is  suf- 
ficient warning  against  the  abuse  of  a  really  excellent  drug.  The  fetor  of 
the  breath  in  these  cases  is  something  horrible,  and  is  due  to  the  presence 
of  decomposing  fat  in  the  saliva  produced  by  the  action  of  mercury  upon 
the  tissues  and  eliminated  bv  the  salivarv  glands.     In  some  cases  of  mer- 


UNTOWARD    EFFECTS    OF    MEECUEY.  491 

curial  stomatitis  the  cheeks,  tongue,  and  lips  are  fearfully  swelled,  perhaps 
ulcerated,  and  covered  with  a  yellowish  pultaceous  deposit  that  is  eminently 
characteristic. 

In  certain  instances  chronic  pains  of  a  rheumatic  character,  muscular 
and  articular,  result  from  mercury.  Experience  shows  that  when  a  patient 
who  is  taking  mercury  begins  to  complain  of  vague  pains  in  the  forearms 
and  legs,  it  is  time  to  stop  the  mercury  and  give  iodin.  A  fact  that  is 
worthy  of  mention  is  that  some  patients  complain  bitterly  of  pains  in  the 
heels,  and  sometimes  the  soles  of  the  feet,  similar  to  that  which  occurs  in 
gonorrheal  rheumatism.  This  is  probably  due  to  mercury.  When  the 
patient  complains  of  his  feet's  being  tender,  the  dosage  of  mercury  should 
be  lessened  and  iodids  given.  There  is  a  serious  question  in  the  author's 
mind  whether  some  of  the  ulcerations  of  the  mouth  and  tongue  in  the  later 
periods  of  syphilis  may  not  be  due  to  injudiciously-given  mercury.  There 
are  many  such  cases  in  which  the  continued  use  of  the  drug  appears  to 
make  matters  worse.  When  iodids  are  substituted  improvement  at  once 
occurs.  This  has  been  attributed  to  the  action  of  the  iodin  in  liberating 
and  revivifying,  so  to  speak,  the  latent  mercury;  but  this  is  not  a  sufficient 
explanation  of  the  beneficial  action  of  iodin.  Chlorate  of  potassium  is  also 
effective. 

Cases  of  syphilis  are  occasionally  met  with  in  practice  that  put  the 
surgeon  at  his  wit's  end  for  suitable  remedies.  The  following  is  an  illus- 
trative case: — - 

Case. — A  woman,  aged  26,  has  been  suflfering  from  an  attack  of  syphilis  for  over 
a  year.  She  has  gone  through  successive  eruptions,  with  their  concomitant  mucous 
lesions,  Avhile  under  active  treatment.  Thus,  she  has  had  the  roseola,  followed  by  a 
papulo-squamous  syphilide  with  mucous  patches  of  a  severe  type,  a  tuberculo- 
squamous  eruption  followed  by  ulcerations  and  accompanied  by  condylomata,  and  two 
attacks  of  iritis.  Experience  has  shown  that  this  patient  is  made  worse  by  mercury. 
Unfortunately,  however,  her  stomach  is  so  irritable  that  iodids  are  not  tolerated  for 
any  length  of  time,  and  the  author  has  therefore  been  forced  to  rely,  for  the  most 
part,  upon  tonics,  coca  having  acted  best  of  any  that  have  been  tried. 

The  use  of  the  iodids  in  syphilis  requires  some  special  notice.  The 
active  element  in  these  salts  is  supposed  to  be  the  free  iodin  that  is  liber- 
ated in  the  system;  but  there  seems  to  be  some  difference  in  the  degree  of 
effect  exerted  by  the  various  salts.  The  potassic  iodicl  is  the  most  powerful, 
but  is  most  liable  to  produce  gastro-intestinal  irritation.  This  does  not, 
however,  impair  its  usefulness  to  any  great  extent;  hence  it  is  the  most 
generally  used  of  all  the  preparations  of  iodin.  The  sodic  salt  is  milder, 
and  is  a  useful  substitute  for  the  potassic  iodid  where  the  j)atient  has  a 
feeble  or  irritable  digestive  apparatus.  The  iodids  are  often  and  success- 
fully used  in  combination,  the  ammonium  iodid  being  combined  with  the 
iodids  of  potassium  and  sodium.  Pure  iodin  is  useful,  but  usually  too 
irritating  to  the  digestive  tract.    The  iodid  of  starch  is  valuable  where  the 


492  TREATMENT    OF    SYPHILIS. 

stomach  is  extremely  irritable.  An  excellent  plan  is  to  have  the  patient 
follow  the  potassic  iodid  by  a  copious  draught  of  dilute  starch-water.  Cal- 
cium iodid  is  valuable,  especially  where  debility  is  a  prominent  factor  in  the 
case.  •  This  salt  deserves  more  extensive  trial.  Where  a  rheumatic  or  gouty 
diathesis  complicates  syphilis,  the  preparation  known  as  the  "tri-iodids"  has 
proved  very  valuable.^  This  preparation  is  a  legitimate  one,  containing  iodin 
in  combination  with  vegetable  alkaloids.  In  passing,  the  author  desires  to 
state  that  the  gouty  or  rheumatic  taint  often  complicates  S5^philis,  and  is 
responsible  for  many  painful  muscular  and  bone  symptoms  usually  attributed 
to  the  syphilis  itself  or,  what  is  more  likely,  to  mercury. 

It  is  an  almost  universal  custom  to  use  iodin  and  its  preparations  only 
in  the  late  periods  of  the  disease,  and  chiefly  in  tertiary  lesions;  but  it  will 
be  found  that  many  cases  of  obstinate  secondary  lesions  will  not  yield  until 
the  iodids  are  given.  As  already  stated,  it  is  well  to  give  a  few  weeks' 
course  of  the  iodids  from  time  to  time,  throughout  the  course  of  mercurial 
treatment.  A  small  amount  of  the  nascent  mercuric  iodid — mixed  treatment 
— may  be  given  at  the  same  time  if  thought  best.  In  precocious  syphilis,  in 
which  destructive  skin-lesions  and  mucous  lesions  or  nerve-changes  come  on 
early  in  the  disease,  the  iodids  are  sometimes  our  chief  reliance.  It  is  in  late 
syphilis,  however,  that  the  iodids  will  be  found  most  reliable,  especially  if 
combined  with  mercury  in  the  form  of  "mixed  treatment."  Gummy  lesions 
require  an  excess  of  the  iodids;  but,  in  all  cases  after  the  lesions  are  under 
control,  a  prolonged  mild  mercurial  course  should  be  instituted.  This  is  the 
proper  method  of  treating  the  deeper  lesions  of  the  brain,  spinal  cord,  bones, 
viscera,  testicle,  etc.;  tubercular  lesions  of  various  kinds;  the  various  scaly 
eruptions;  and  those  later  syphilides  that  tend  to  aggregate  themselves  in 
groups  or  become  particularly  obstinate.  As  an  example  of  the  mixed  treat- 
ment, the  following  is  an  eligible  formula: — 

IJ  Hydrarg.  bichloridi gr.  iv. 

Ammon.   iodidi 3iij. 

Kalii   iodidi 3v  9  j. 

Tr.  cinchon.  co.,  or 

Syr.  sarsap.  co §iv. 

M.     Sig. :    3j  in  a  wineglass  of  water  after  each  meal. 

Where  it  is  desirable  to  use  an  alterative  tonic  in  combination  with  the 
iodids  the  author  frequently  gives  the  "elixir  of  the  three  chlorids."  This 
is  a  very  reliable  and  elegant  mixture.^  The  formula  contains  in  each 
dram : — 

Protochlorid  of  iron,  gr.  Vs;  bichlorid  of  mercury,  gr.  V128;  ehlorid  of  arsenic, 
gY.  ^/eso;    combined  with  calisaya,  alkaloids,  and  aromatics. 

A  desirable  formula  is  as  follows: — 

^  The  "tri-iodids"  and  "three  chlorids"  are  prepared  by  the  Henry  Phamiacal  Co., 
of  Louisville,  Ky. 


EFFECT    OF   THE    lODIDS.  493 

IJ  Kalii  iodidi 3ii3ij. 

Ammon.  chloridi 3ii  3  ij . 

Liq.  fenisenici   (Henry) Biv. 

M.     Sig. :    3i  to  3ij  after  each  meal. 

When  it  is  necessary  to  stop  active  treatment  the  author  frequently 
gives  a  tonic  course  of  the  elixir  of  the  chlorids  alone. 

Potassium  chlorate  is  often  of  great  service  in  the  treatment  of  syphilis. 
The  occasional  alternation  of  a  two  or  three  weeks'  course  of  this  drug  with 
the  routine  mercurial  course  often  gives  excellent  results,  especially  where 
lesions  of  the  mouth  exist. 

Gunn's  "three-eights"  mixture  is  an  excellent  one  for  the  administra- 
tion of  iodin.    It  is  as  follows: — 

I^  lodinii   resubl » gr.  viij. 

Potass,  iodidi 3viij. 

Syr.  sarsap.  co , §viij. 

M.     Sig.:    3j  dose. 

Patients  should  be  impressed  with  the  necessity  of  freely  diluting  iodin 
or  iodid  preparations  before  taking,  as  they  are  all  more  or  less  irritating  to 
the  stomach.  So  far  as  possible,  they  should  be  taken  after  meals.  In  some 
instances,  however,  in  which  the  patient's  digestive  organs  are  not  very 
sensitive,  the  iodids  may  be  taken  with  advantage  while  fasting,  especially 
if  combined  with  a  vegetable  bitter  like  quassia  or  cinchona  or  with  some 
carbonated  water  such  as  the  sparkling  Garrod  spa  or  apollinaris.  In  the 
formulas  given  for  the  mixed  treatment  the  combination  of  incompatibles 
and  the  irritating  bichlorid  seem  greatly  in  evidence,  but  the  ingredients 
are  rationally  compatible,  although  not  chemically  so.  There  is  a  chemic 
reaction  in  the  mixture  that  results  in  the  formation  of  the  biniodid,  which 
is  very  active  by  virtue  of  its  nascent  condition.  When  it  is  necessary  to 
push  the  dose  of  the  iodids,  this  may  be  done  by  adding  a  saturated  solution 
of  sodic  or  potassic  iodid,  in  doses  of  10  drops  (or  5  minims,  representing  5 
grains)  thrice  daily  to  begin  with,  to  be  subsequently  increased  2  drops,  or 
1  minim,  daily  per  dose  until  the  limit  of  tolerance  has  been  reached  or 
the  symptoms  yield,  when  the  dose  may  be  reduced,  the  favorable  result 
meanwhile  continuing. 

It  is  sometimes  necessary  to  use  mercurial  inunctions  in  addition  to 
the  iodids,  and  the  local  application  of  the  oleate  is  often  of  great  assistance 
in  the  cure  of  obstinate  skin-lesions.  The  deep-seated  ulcerations — especially 
those  of  the  throat,  syphilis  of  the  bones,  and  syphilis  of  the  brain  and  cord 
— often  require  enormous  doses  of  the  iodids  before  they  exhibit  any  signs 
of  yielding.  During  the  author's  service  in  the  venereal  wards  of  the  New 
York  Charity  Hospital  a  daily  dose  of  200  or  300  grains  of  potassic  iodid  was 
nothing  unusual,  and  Van  Buren  relates  a  case  in  which  900  grains  were 
given  daily  for  eleven  days.     The  author  has  had  a  number  of  eases  in 


494  TEEATMEXT    OF    SYPHILIS. 

priyate  practice  in  which,  the  drug  was  increased  to  a  daily  allowance  of  from 
300  to  600  grains.  Much  depends  upon  the  purity  of  the  drug.  Potassic 
iodid  is  often  largely  adulterated  with  potassic  hromid,  which  makes  the 
supposed  iodid  readily  tolerated.  Making  due  allowance  for  adulterations, 
however,  the  doses  tolerated  hy  some  patients  are  amazing.  There  is  great 
variation  in  the  tolerance  of  different  patients  for  the  iodids.  Some  will 
take  several  hundred  grains  daily  for  weeks,  while,  on  the  other  hand, 
cases  are  met  with  that  will  not  tolerate  the  most  minute  doses  of  the 
iodids.  The  degree  of  tolerance  of  potassic  iodid  exhibited  by  different 
patients  greatly  depends  upon  the  general  management  of  the  constitu- 
tional condition.  The  iodids  produce  great  debility  and  wasting  when  given 
in  large  doses,  unless  great  care  be  used. 

Many  cases  of  late  syphilis  are  suff'ering  with  two  conditions,  viz.: 
the  debility  produced  by  long-continued  syphilis,  and  the  malnutrition  and 
anemia  incident  to  injudicious  mercurial  treatment.  Great  care  is  always 
necessary  in  such  cases  to  keep  up  general  nutrition.  If  the  syphilis  per  se 
be  treated,  injury  is  apt  to  be  done;  but,  if  the  syphilis  be  relegated  to  the 
background  and  the  patient  himself  attended  to,  much  good  may  be  accom- 
plished. Some  patients  who  have  sequels  of  syjDhilis  and  who  have  taken 
more  or  less  mercury  in  times  past,  state  that  they  "cannot  stand  mercury." 
To  such  patients  the  physician  may  usually  safely  say  that  they  not  only 
can  tolerate  mercury,  but  that  they  probably  can  take  it  and  grow  fat  at 
the  same  time.  Mercury  produces  effects  that  vary  greatly  according  to 
the  idiosyncrasy  and  resisting  power  of  the  patient,  and  the  dose,  prep- 
aration, and  method  of  administration  of  the  drug.  Given  in  minute 
doses  in  combination  with  the  iodids,  it  acts  as  a  powerful  tonic.  The 
proper  method  of  administration  of  potassic  iodid  in  late  syphilis  is  in  the 
form  of  the  saturated  solution,  as  already  designated.  At  the  same  time, 
the  formula  for  the  mixed  treatment,  with  a  dose  of  the  bichlorid  not  to 
exceed  ^/ga  of  a  grain,  should  be  given.  The  dose  of  the  iodid  can  be  in- 
creased by  drops  as  required.  Codliver-oil  and  iron  are  alwa3^s  necessary 
in  these  cases.  The  oil  may  be  given  as  an  emulsion,  and  the  iron  in  the 
form  of  the  diah'zed  iron  or  syrup  of  the  iodid.  As  illustrative  of  the  ex- 
cellent effects  of  this  method  of  management,  the  following  cases  are  in- 
structive, although  in  no  sense  remarkable: — 

Case  1. — A  physician,  35  years  of  age,  contracted  syphilis  at  the  age  of  twenty- 
eight,  and  went  through  a  more  than  ordinarily  severe  course  of  the  disease.  Two 
years  after  the  commencement  of  his  trouble  extensive  ulcerations  appeared  upon 
his  right  leg,  and,  as  the  veins  of  his  limb  were  varicose,  the  lesions  proved  very 
obstinate,  and  had  never  perfectly  healed.  In  the  meantime  the  patient  had  be- 
come thoroughly  disgusted  with  mercuiy  on  account  of  injudicious  treatment  early 
in  the  case.  At  the  time  he  Avas  first  seen  debility  was  quite  marked.  Potassic 
iodid  in  increasing  doses,  with  ^/ss  grain  of  the  bichlorid,  Avere  ordered,  and,  later  on, 
a  mixture  of  syr.  ferri  iod.  and  ol.  morrhuae.  Antiseptic  strapping  constituted  the 
local  treatment.     The  oil  and  iron  were  ordered  in  shen-y-wine  after  meals,  and  the 


UNTOWAED    EFFECTS    OF    lODIX.  4:95 

patient  was  as  much  surprised  as  gi-atified  at  this  prescription.  Improvement  was 
rapid,  and  the  patient  gained  fourteen  pounds  in  weight  in  about  four  weeks,  the 
ulcer  nieanwliile  cicatrizing  completely. 

Case  2. — A  Avoman  of  30  consulted  the  author  in  regard  to  necrosis  of  the  palate 
and  nasal  and  superior  maxillaiy  bones.  Small  portions  of  necrosed  bone  were 
removed  from  time  to  time.  Tonic  doses  of  mercury  with  increasing  doses  of  potassie 
iodid,  in  combination  with  oil  and  iron  were  given.  Although  she  was  much  debili- 
tated, the  dose  of  iodid  was  increased  until  180  grains  per  diem  were  taken,  and 
with  the  best  results.  The  nose  and  throat  improved,  the  necrosis  ceased,  and  the 
patient  gained  about  twelve  pounds  weight  in  the  course  of  a  month. 

Case  3. — This  case  was  that  of  a  man  of  33  years  who  had  lesions  of  the  nose 
and  pharynx  similar  to  those  of  Case  2.  Anemia  was  not  marked,  but  wasting  was 
quite  pronounced.  The  patient  stated  that  he  could  not  take  potassie  iodid,  as  it 
disturbed  his  stomach  and  made  him  thin.  Under  the  treatment  already  recommended 
this  patient  was  finally  given  nearly  200  grains  of  jaotassic  iodid  daily,  for  at  least  two 
weeks.  At  the  end  of  six  weeks'  treatment  he  had  gained  seventeen  pounds  in 
weight,  and  returned  to  his  home  in  a  neighboring  city  in  better  health  than  at  any 
time  since  he  contracted  his  syphilis. 

A  number  of  similar  cases  might  be  described,  but  the  histories  above 
given  are  sufficient  to  illustrate  what  judicious  treatment  can  do  in  late  syph- 
ilis, and  are  consequently  as  valuable  as  a  larger  number  would  be. 

Untowaed  Effects  of  Iodix. — Like  the  unpleasant  effects  of  mercury, 
those  of  iodin  require  more  than  casual  attention.  In  the  first  place,  the 
iodids  may  cause  sudden  and  severe  ptyalism  in  patients  who  have  been 
taking  mercury  freely,  simply  by  suddenly  liberating  and  rendering  active 
the  latter  drug.  On  this  account,  caution  should  be  exercised  in  the  use  of 
the  iodids  in  such  cases  as  have  been  under  a  prolonged  course  of  mercurials. 
It  will  also  be  found  in  every  case  that  iodin  has  a  special  action  upon 
the  salivary  glands,  whether  the  patient  has  been  taking  mercury  or  not. 
"Within  a  very  short  time  after  taking  a  full  dose  of  potassie  iodid  the 
iodin  can  be  distinctly  tasted,  and  the  saliva,  and  mucus  from  the  nasal 
passages,  will  exhibit  a  decidedly  yellowish  tinge.  The  nasal  mucus,  espe- 
cially, will  be  greatly  increased  in  amount. 

lodism. — The  most  important  of  the  evils  that  may  be  caused  by  the 
iodids  is  the  condition  known  as  "iodism."  This  consists  in  a  feeling  of 
depression  and  malaise,  nervous  irritability,  tinnitus  aurium;  neuralgic 
or  rheumatic  pains  in  various  situations,  especially  in  the  bones  and  muscles; 
and  irritation  of  the  various  mucous  surfaces,  especially  those  of  the  eyes 
and  nose.  The  latter  symptom  may  be  merely  a  mild  coryza  or  may  amount 
to  a  very  severe  inflammatory  edema  of  the  conjunctiva  and  nasal  and 
lacrymal  apparatuses.  Violent  diarrhea  and  vomiting,  with  severe  griping 
pain,  may  occur  from  the  irritant  action  of  the  drug  upon  the  gastro-in- 
testinal  mucosa,  and  may  necessitate  its  complete  suspension  for  a  time. 
Often,  however,  the  treatment  may  be  continued  by  substituting  the  sodic 
for  the  potassie  salt,  limiting  the  diet  to  rice  and  milk,  and  giving  large 
doses  of  subnitrate  of  bismuth.     When  given  as  already  suggested,  by  be- 


496  TEEATMEXT  OF  SYPHILIS. 

ginning  with  small  doses  and  gradually  increasing  until  the  limit  of  toler- 
ance is  reached^  there  is  usually  little  difficulty  in  administering  large  doses 
of  the  iodids.  An  excellent  method  for  the  administration  of  the  iodids  in 
cases  of  intolerance  is  to  mix  the  drug  with  a  large  quantity  of  lithia-water. 
Twenty  to  60  grains  of  sodic  or  potassic  iodid  may  be  dissolved  in  2  to  4 
quarts  of  water  and  drunk  during 'twenty-four  hours.  The  eliminative  ac- 
tion of  the  water  itself  is  of  great  benefit  in  syphilis.  There  is  no  better 
adjuvant  to  treatment  than  drinking  large  quantities  of  pure  water. 

lodin  Eruptions. — Some  persons  are  the  subjects  of  an  idiosyncrasy 
that  renders  them  peculiarly  liable  to  eruptive  phenomena,  even  when  small 
doses  are  given.  The  author  has  a  patient  at  the  present  time  who  cannot 
take  potassic  iodid  in  10-grain  doses  for  a  day  without  the  development  of 
multiple,  red,  painful  swellings — erythema — upon  his  limbs.  Some  pa- 
tients are  liable  to  extreme  iodism  from  very  small  doses.  A  professional 
gentleman  of  the  author's  acquaintance  cannot  tolerate  the  drug  in  doses 
of  2  or  3  grains  without  the  development  of  a  severe  coryza  within  a  few 
hours.    In  another  case  a  ^/4-grain  dose  causes  typic  iodism. 

There  are  three  principal  forms  of  eruption  that  may  result  from  iodin 
and  the  iodids,  viz.:  acne,  erythema,  and  purpura.  Of  these  eruptions  acne 
is  the  most  frequent,  and  may  be  slight  or  quite  extensive,  the  pustules 
varying  from  the  size  of  the  head  of  a  pin  to  quite  extensive  phlegmonoid 
abscesses.  Iodin  erythema  is  usually  situated  upon  the  nose,  cheeks,  or 
forehead,  and  is  followed  by  branny  desquamation.  It  may,  however,  merge 
into  eczema.  Any  of  these  forms  of  eruption  may  be  attended  by  consider- 
able heat  and  itching. 

Severe  and  well-marked  purpura  hemorrhagica  is  occasionally  noted 
in  cases  of  syphilitic  sequels  treated  by  large  doses  of  potassic  iodid.  Such 
patients  suffer  from  the  combined  evil  propensities  of  the  syphilitic  cachexia 
and  large  doses  of  iodin.  This  explains  the  profound  blood-changes  to 
which  the  purpuric  extravasations  are  attributable.^  Fatal  cases  of  iodin 
poisoning  have  been  reported;  hence  a  certain  amount  of  caution  must 
be  exercised  in  cases  in  which  there  is  a  marked  contra-indicating  idiosyn- 
crasy. A  case  is  reported  of  a  man  with  cardiac  hypertrophy  and  subacute 
renal  disease  who  died  as  a  result  of  the  administration  of  30  grains  of 
potassic  iodid  during  a  period  of  about  thirty-six  hours.  It  is  quite  easy  to 
explain  the  manner  in  which  idiosyncrasy  acted  in  this  case.  The  abnor- 
mally irritating  effect  of  the  iodid  completely  suspended  the  action  of  the 
kidneys,  these  organs  being  already  impaired  by  disease.  Such  cases  serve 
as  a  warning  against  giving  iodin  freely  to  nephritics  until  we  are  certain 
that  no  idiosyncrasy  exists.  Eenal  disease  alone  is  not  necessarily  a  contra- 
indication for  the  iodids.  On  the  contrary,  they  are  often  of  great  value  in 
the  treatment  of  the  renal  disease  itself. 


^  Otis  claims  to  have  seen,  as  a  result  of  the  iodids,  patches  resembling  diph- 
theritic deposit  upon  the  mucous  membrane. 


NEW   EEMEDIES    FOE    SYPHILIS.  497 

All  of  the  evil  effects  of  the  iodids  rapidly  disappear  upon  the  cessation 
of  the  drug  and  the  administration  of  such  tonics  as  quinin,  iron,  and  cod- 
liver-oil,  with  free  doses  of  such  diuretics  as  the  potassic  citrate  or  acetate. 
The  cause  of  the  evil  phenomena  described  is  usually  defective  action  of 
the  kidneys, — i.e.,  defective  elimination;  hence  the  advisability  of  pro- 
moting free  diuresis  during  a  course  of  the  iodids.  Acne,  in  certain  special 
cases  of  idiosyncrasy,  may  be  prevented  by  the  administration  of  Fowler's 
solution  of-  arsenic,  conjointly  with  the  iodids. 

Neiv  Remedies  for  Syphilis.- — There  is  a  tendency  on  the  part  of  the 
profession  to  recommend  various  new  and  questionable  preparations  in 
the  treatment  of  syphilis.  Certain  vegetable  preparations  have  enjoyed  a 
more  or  less  long-lived  popularity  in  this  respect.  Sarsaparilla  was  long 
thought  to  be  a  specific.  Among  the  new  preparations  are  cascara  amarga, 
berberis  aquafolium,  and  stillingia,  alone  or  in  combination.  A  trial  of 
these  things  demonstrates  their  unreliability  and  shows  more  plainly  than 
ever  the  value  of  iodin  and  mercury.  As  bitter  tonics  the  vaunted  vegetable 
preparations  are  all  more  or  less  useful,  but  as  specifics  they  are  arrant 
humbugs.  A  certain  quasiproprietary  medicine  composed  of  various  vege- 
table ingredients  was  introduced  as  a  specific  a  few  years  since,  and  unfortu- 
nately fathered  by  no  less  a  man  than  the  elder  Sims.  As  a  matter  of  fact, 
it  is  a  fairly  eligible  combination  of  vegetable  tonics,  useful  enough  as  such, 
but  without  the  slightest  justifiable  claim  as  a  specific  therapeutic  agent. 
Tayuga,  another  remedy  of  doubtful  origin  that  was  recommended  as  a  spe- 
cific some  years  ago,  has  been  given  a  fair  trial  in  syphilis,  but  with  negative 
results.  The  bichromate  of  potassiiim  has  been  recommended,  but  the  author 
has  had  no  experience  with  it.  This  drug  was  first  introduced  as  a  remedy 
for  syphilis  by  Gtintz,  of  Dresden,  who  claims  surprisingly  good  results  froni 
its  use.  He  at  first  gave  gr.  Vis  i^  combination  with  potassium  nitrate, 
three  times  a  day,  but  subsequently  obtained  better  effects  from  what  he 
styles  "chromwasser,"  which  consists  of  a  solution  of  potassic  bichromate  in 
carbonic-acid  water.  With  this  preparation,  he  claims  to  be  able  to  give 
3  ^/2  grains  of  the  drug  daily,  the  quantity  of  carbonated  water  necessary 
being  about  6000  grammes.  The  remedy  is  to  be  given  after  meals.  Giintz 
•claims  that  this  remedy  is  curative  in  syphilis  on  account  of  its  powerful 
oxidizing  properties. 

While  it  is  undoubtedly  best  to  be  liberal  with  respect  to  the  various 
new  remedies  for  syphilis  and  give  different  remedies  a  fair  trial,  irrespective 
of  their  origin,  the  proportion  of  cases  of  syphilis  that  is  curable  by  the 
judicious  use  of  mercury  and  iodin  is  so  large  and  so  gratifying  that  the 
practitioner  is  hardly  warranted  in  wasting  much  time  upon  new  and 
strange  drugs.^ 


^Taylor  estimates  the  proportion  of  cures  under  mercury  and  iodin  at  about  95 
per  cent.,  but  this  is  probably  too  optimistic. 


498  TEEATMEXT  OF  SYPHILIS. 

Two  remedies  that  have  been  decidedly  beneficial  as  tonics  in  syphilis, 
in  the  authors  experience,  are  the  fluid  extract  of  coca  and  iodoform. 
Coca  is  an  excellent  tonic  when  used  conjointly  with  strictly  antisyphilitic 
treatment,  and  tends  decidedly  to  relieve  the  nervous  depression  from  which 
most  syphilitics  suffer.  It  may  sometimes  be  combined  with  sherry  or  port 
wine  with  advantage.    Tajdor  also  praises  the  erythroxylon  coca  as  follows: — 

Its  marked  tonic  effect  upon  the  heart,  nervous  system,  and  capillaries,  and  its 
power  to  invigorate  the  system,  improve  nutrition,  and  sustain  life  is  so  great 
that  its  use  in  syphilis,  secondary  to  that  of  mercury  and  of  potassium  iodid  is 
attended  by  results  which  no  other  agent  known  to  us  possesses.  It  is  especially 
useful  in  the  anemia  and  cachexia  of  the  secondary  period,  and  in  marked  debilitated 
and  cachectic  conditions  at  all  stages  of  the  disease. 

Iodoform  will  be  found  quite  useful  in  cases  that  do  not  tolerate  mer- 
cury and  iodin  well,  and  should  be  combined  with  the  exsiccated  sulphate 
of  iron  or  iron  by  hydrogen,  the  latter,  perhaps,  being  the  most  useful  and 
convenient.  Ferratin  and  peptomangan,  new  preparations  of  iron,  are  very 
useful.  It  is  pleasant  and  readily  assimilable.  There  are  two  other  drugs 
which,  while  not  in  any  sense  curative,  are  very  beneficial  in  S3q3hilis.  These 
are  the  potassic  chlorate  and  amnionic  chlorid.  The  former  in  doses  of  a 
tablespoonful  of  the  saturated  solution  thrice  daily  seems  to  act  very  well 
when  conjoined  with  the  regular  mercurial  course,  particularly  when  oral  or 
faucial  lesions  are  prominent  symptoms.  The  amnionic  chlorid  assists  in 
dissolving  the  young  connective  tissue  or  plastic  deposit  that  forms  the  bulk 
of  syphilitic  lesions.  It  has  seemed  especially  useful  in  nervous  syphilis. 
It  is  best  given  in  combination  with  the  ordinary  mixed  treatment.  Du- 
mesnil  also  claims  excellent  results  from  this  drug. 

The  internal  administration  of  gold  has  been  vaunted  in  the  treatment 
of  some  phases  of  syphilis.  Xo  preparation  of  gold  has  in  the  slightest 
degree  a  specific  effect,  unless  combined  with  mercury.  Gold,  per  se,  is, 
however,  of  value  in  the  syphilitic  cachexia,  and  in  some  of  the  nervous 
sequels  of  s^'philis.  The  combinations  of  gold  and  arsenic  and,  more  espe- 
cialh',  of  gold  and  mercur}',  devised  by  Barclay,  and  Clark's  solution  of  the 
chlorid,  are,  so  far  as  the  author  is  aware,  the  only  ^ireparations  in  which 
gold  is  present  in  an  assimilable  form.  These  formulas  often  give  excellent 
results. 

Local  Teeatmext  of  Syphilis. — Before  leaving  the  subject  of  the 
treatment  of  syjihilis  the  author  desires  to  call  particular  attention  to  cer- 
tain items  in  the  local  management  of  the  disease  that  have  proved  of  great 
service  in  his  own  practice. 

There  is  little  to  add  to  what  has  already  been  said  regarding  the  treat- 
ment of  the  chancre  itself,  save  in  the  way  of  recapitulation,  but  some  of 
the  skin-lesions  and  mucous  lesions  demand  more  exhaustive  consideration. 

Local    Treatment    of    tlie    Chancre. — First    principle,    avoid    caustics. 


LOCAL    TREATMENT    OF    SYPHILITIC    LESIOXS.  499 

Second  principle,  avoid  grease.  Third  principle,  keep  the  part  dr}^,  as  a 
rule,  and  perfectly  clean. 

A  clear  understanding  of  the  merits  of  the  chancre  per  se  will  prevent 
many  foolish  patients  from  applying  caustics,  liniments,  and  filthy  salves 
prescribed  by  their  friends  or  by  various  doctors  to  whom  they  apply,  one 
after  the  other,  in  search  of  the  impossible— a  three  days'  cure.  It  would 
seem  unnecessary  to  warn  physicians  against  the  use  of  caustics  in  syphilitic 
chancre;  but  the  specialist — who  sees  so  many  cases  of  chancre  tortured 
into  serious  inflammation,  and  perhaps  sloughing,  by  copper  sulphate  or 
silver  nitrate  in  the  hands  of  general  practitioners  and  drug-clerks — knows 
full  well  the  practicality  and  importance  of  such  warning. 

A  very  important  point  in  the  management  of  severe  chancre  is  the 
maintenance  of  rest.  Movement  and  friction  are  often  responsible  for 
serious  complications  of  chancre.  That  sexual  intercourse  should  be  inter- 
dicted goes  without  the  saying.  Eegarding  the  latter  point,  the  patient 
should  be  duly  impressed  with  the  danger  of  contagion.  He  should  under- 
stand that  the  slightest  abrasion  upon  his  penis,  occurring  at  any  time 
within  three  years  after  infection,  may  infect  the  female.  The  married 
man  who  understands  this  and  is  careless  must  assume  all  responsibility 
for  evil  results. 

The  only  exceptions  to  the  rule  regarding  caustics  are  mixed  sores,  with 
a  minimum  of  induration,  and  exulcerated  sores  that  become  sluggish  and 
refuse  to  heal  after  induration  has  nearly  or  q^uite  disappeared.  In  the 
first  instance  pure  carbolic  acid  followed  by  fuming  nitric  acid  is  admissible, 
but  the  galvanocautery,  preceded  by  cocaine,  is  better.  In  sluggish  ulcers 
stimulation  with  silver  nitrate  may  be  warrantable. 

The  exception  to  the  rule  regarding  grease  is  the  application  of  iodo- 
form ointment  to  sluggish  or  painful  sores.  The  following  formula  will  be 
found  to  be  excellent,  the  odor  of  the  iodoform  being  well  disguised.  The 
author  attributes  this  property  to  the  menthol. 

IJ  Mentholis gr.  v. 

lodoformi     3iv. 

Cetacei   alb.  ._ 3ij. 

Cerati q.  s.  ad  Bj- 

M.     Sig. :    Apply  on  lint. 

Oil  of  mirbane  may  be  used  in  lieu  of  menthol,  but  is  more  irritating 
and  less  effective  when  used  in  ointment.  Where  there  is  considerable  pain, 
cocain  and  extract  of  belladonna  may  be  added: — 

IJ  01.   mirbani m.  iv. 

Bals.   Peru 3iij . 

lodoformi    3ij. 

Vaselini    q.  s.  ad  §j. — M. 

The  old-time  black  and  yellow  washes  are  serviceable,  although  the 
part  cannot  be  kept  dry  under  their  use.     A  solution  of  mercuric  chlorid 


500  TEEATMEXT  OF  SYPHILIS. 

1  to  1000  is  very  useful.  A  plan  recommended  for  the  application  of  the 
bichlorid  is  to  wash  the  lesion  with  a  weak  solution  of  common  salt.  Calomel 
is  now  sprinkled  upon  the  part,  a  small  amount  of  nascent  and  active  bi- 
chlorid being  thus  formed.  The  author  has  used  this  plan  for  condylomata 
quite  successfully.  The  best  absorbent  for  the  dry  treatment  is  the  pow- 
dered oleate  or  stearate  of  zinc.    A  useful  combination  is  the  following: — 

IJ  Bismutlii   subnitratis 3iij. 

Ac.   salicylatis gr.  ij. 

Zinci  oleatis q.  s.  ad  §j . — M. 

Simple  calomel  is  also  serviceable.  Turpeth  mineral  affords  a  very  de- 
sirable method  of  applying  a  mercurial  in  a  dry  form.  Oxid  of  zinc  and 
lycopodium  are  also  very  good,  used  in  equal  parts.  The  part  may  be  kept 
dry  by  absorbent  cotton.  Cumbersome  dressings  must  be  avoided,  especially 
such  as  require  for  their  retention  constriction  of  the  penis. 

Pronoimced  induration  often  persists  for  months  without  ulceration, 
or  after  a  concomitant  ulcer  has  healed.  Bathing  in  hot  water,  with  fric- 
tions of  hydrarg.  oleat.,  5  per  cent.,  will  usually  resolve  them  after  a  time. 
The  easiest  and  best  method  is  excision.  There  is  often  no  objection  to  early 
excision  of  clearly-cut  chancres  upon  the  prepuce  or  integument.  Care 
should  be  taken,  however,  never  to  excise  them  until  they  have  become 
stationary,  else  recurrence  is  almost  certain. 

Local  Treatment  of  Shin-lesions. — The  roseola  seldom  requires  atten- 
tion. If,  however,  pigmentation  is  marked  and  lasting,  hot  baths  with  fric- 
tions of  20-per-cent.  oleate  will  be  serviceable.  In  ordering  the  oleate 
Squibb's  should  be  specified.  There  may  be  others  quite  as  good,  but  not 
to  the  author's  knowledge;    certainly  there  are  none  better. 

Papules,  tubercles,  squamas,  and  other  dry  lesions  can  be  controlled 
and  rapidly  resolved  by  applications  of  the  following  formulas.  Care  should 
be  taken  in  the  selection  of  the  proper  strength — ^blistering  may  result,  and, 
though  sometimes  beneficial,  is  likely  to  cause  the  patient  to  lose  confidence. 
There  is  great  variation  in  integumentary  susceptibility.  The  collodion 
preparation  is  the  one  that  is  most  likely  to  blister:- — 

IJ  Hydrarg.  bichloridi gr.  v  to  gr.  x. 

Collodionis    Bj. 

M.     Sig. :    Apply  Avith  eamel's-hair  pencil. 

ij  Hydrarg.    bichloridi gr.  v  to  gr.  x. 

Tr.  benzoini  co §J. 

M.     Sig. :    Apply. 

Tincture  of  Tolu  is  also  an  excellent  vehicle  for  the  local  application 
of  mercuric  chlorid. 

The  results  obtained  by  these  preparations  are  often  remarkable.  They 
are  of  especial  value  in  removing  facial  blemishes;  they  hasten  removal 
of  pigmentation  very  niarkedly.    Their  efficacy  is  easily  tested  by  contrast- 


LOCAL    TEEATMENT    OF    SYPHILITIC    LESIONS.  501 

ing  the  course  of  facial  lesions  treated  by  them  with  that  of  other  integu- 
mentary lesions  upon  the  same  patient. 

The  solution  of  bichlorid  in  compound  tincture  of  benzoin  is  often 
better  than  the  collodion  solution.  It  is  less  apt  to  blister  and  may  be 
intrusted  to  the  patient  for  application.  It  is,  however,  rather  disagreeable 
in  that  it  discolors  the  skin,  and  is  with  difficulty  removed.  The  oleate  of 
copper,  recommended  by  Shoemaker  for  freckles  and  other  pigmentary 
lesions  of  the  skin,  seems  to  act  well  in  removing  the  discolorations  left  by 
the  syphilides.  Soaps  containing  mercury  bichlorid  are  also  useful.  In 
ecthymatous  or  rupial  ulcerations  applications  of  the  oleate  of  mercury  or 
mercurial  plaster  are  beneficial. 

Crusts  and  squamas,  if  thick,  are  benefited  by  applications  of  ung. 
hydrarg.  nitrat.  to  the  sublying  lesions.  The  ammoniated-mercury  oint- 
ment is  useful  in  some  instances.  Where  the  lesions  are  very  obstinate,  an 
occasional  application  of  the  pure  acid,  hydrarg.  nitrat.  after  removal  of  the 
crusts  will  hasten  resolution. 

Ulcers  require  especial  care.  Ointments  of  iodoform,  hydrarg.  oleat., 
ung.  hydrarg.,  the  citrin  and  white-precipitate  ointment  are  all  of  service 
in  different  cases;  one  failing,  another  should  be  used.  Occasional  stimula- 
tion with  argent,  nitrat.  or  even  the  acid  nitrate  of  mercury  may  be  re- 
quired. Should  ulcerations  be  attacked  by  phagedena,  Eicord's  paste,  bro- 
min,  or  the  actual  cautery  may  be  used.  The  author's  preference  is  for  pure 
bromin.  Applications  of  the  potassio-tartrate  of  iron — 20  grains  to  the 
ounce — are  effective  in  some  cases.  Ulcers  may  require  excision  of  under- 
mined edges  and  curettement. 

Nodes  and  diffuse  osteoperiosteal  swellings  may  usually  be  resolved  by 
frictions  of  ung.  hydrarg.,  hydrarg.  oleat.,  or  ung.  iodinii  co.  The  author 
has  obtained  good  results  from  hypodermics  of  a  solution  of  the  bichlorid 
immediately  contiguous  to  the  swelling.  A  blister,  followed  by  ung. 
hydrarg.,  is  often  efficacious  in  disposing  of  obstinate  nodes.  The  tincture 
of  iodin  is  also  useful. 

Necrosis  of  the  bones  in  various  situations  is  often  encountered  in  late 
syphilis:  i.e.,  the  period  of  sequels.  An  effort  should  be  made  to  determine 
whether  the  osseous  troubles  are  due  to  syphilis  or  to  mercury.  Whether 
syphilitic  or  not,  however,  such  cases  must  be  treated  largely  upon  general 
principles.  Tonics  are  always  indicated.  The  iodids  are  our  main  reliance, 
mercury,  if  given  at  all,  being  indicated  only  in  tonic  doses.  The  following 
case  is  a  fair  illustration  of  the  destruction  sometimes  produced  by  necrosis 
in  late  syphilis: — 

Case. — A  young  man  of  30  vras  referred  by  his  physician  for  a  possible  operation 
upon  the  naso-pharyngeal  cavity  for  the  removal  of  dead  bone.  The  palatal  and  nasal 
bones  were  found  to  have  been  entirely  destroyed.  Destructive  ulceration  had  already 
attacked  the  vault  of  the  pharynx  and  was  threatening  the  osseous  structures  at 
the  base   of  the   skull.     Mercurial   treatment  had  been   persisted   in   for   the   entire 


502  TEEATME'S'T    OF    SYPHILIS. 

course  of  the  disease,  which  had  been  contracted  nine  years  before.  A  few  small 
scales  of  necrosed  bone  that  Avere  partially  detached  were  removed,  and  the  patient 
put  upon  tonics  and  increasing  doses  of  the  iodid.  Improvement  was  quite  rapid,  the 
lesions  healed,  and  the  patient  was  sent  home  at  the  end  of  six  weeks  in  compara- 
tively good  health. 

The  obstinate  headaches  of  both  late  and  early  syphilis,  whether  asso- 
ciated with  cranial  bone-lesions  or  not,  are  benefited  by  frictions  of  the  scalp 
with  hydrarg.  oleat. — 10  per  cent.  The  nng.  hydrarg.  is  also  serviceable. 
In  obstinate  cases  a  blister  to  the  nncha,  followed  by  mercnrial  plaster,  is 
quite  effective.  There  are  occasional  cases  of  cephalalgia  associated  with  the 
cachexia  sypliilitica  where  the  galvanic  current  is  of  great  service.  Bromids 
in  large  doses  sometimes  act  well.  Leeches  are  often  useful.  The  possible 
indication  of  elimination  of  toxins  should  be  borne  in  mind. 

Mucous  Patches. — Mucous  patches  sometimes  give  great  annoyance, 
and  refuse  to  yield  to  purely-constitutional  treatment,  becoming  sluggish 
and  indolent.  In  such  an  event  the  pure  acid  nitrate  of  mercury  will  be 
found  to  be  the  best  application.  Before  applying  it  the  lesion  should  be 
dried  with  a  piece  of  bibulous  paper  or  absorbent  cotton.  The  surface 
should  then  be  thoroughly  cauterized,  after  which  it  should  be  again  dried. 
The  nitrate  of  silver  may  be  used  in  the  same  manner.  Sometimes  cauter- 
ization is  not  tolerated,  the  lesion  becoming  inflamed  and  irritable.  In  such 
cases  the  tr.  benzoin  co.,  either  alone  or  in  combination  with  the  mercuric 
chlorid,  will  be  found  most  effective.  .  It  coats  the  lesion  with  a  deposit 
of  gum  benzoin,  and,  in  addition  to  its  mildly  stimulant  and  antiseptic 
action,  protects  the  surface  from  irritation.  When  mucous  patches  hyper- 
trophy and  form  tubercles  or  condylomata,  an  application  of  hydrarg. 
bichlor.  in  collodion,  4  to  20  grains  to  the  ounce,  will  be  found  to  remove 
them  very  rapidly.  Calomel,  zinc  oxid,  salicylic  acid,  and  iodoform  are 
also  quite  useful  aj^plications. 

Salicylic-acid  ointment  or  plaster  and  chrysarobin  are  very  useful  appli- 
cations in  the  scaly  syphilides  and  syphilitic  "psoriasis."  The  following 
formula  is  useful  in  the  latter  condition: — 

B^  01.   cadini '.  .  .  .  3ij. 

Ung.  hydrargyri §ss. 

Lanolini  q.  s.  ad  Bj. 

M.  To  be  used  by  inunction,  morning  and  evening,  for  syphilitic  psoriasis  of 
the  palms  and  soles. 

Washing  the  ^jarts  in  salt  solution,  followed  by  the  application  of  calo- 
mel is  also  of  service,  as  nascent  bichlorid  of  mercury  is  formed  and  acts 
very  powerfully  upon  the  lesions.  Very  obstinate  skin-lesions  will  often  be 
found  to  improve  rapidly  under  mercurial  fumigations,  after  all  other 
methods  of  treatment  have  proved  inefficacious. 


LOCAL    TREATMENT    OF    SYPHILITIC    LESIOXS.  503 

Continuous  applications  of  oleate  of  mercury  or  mercurial  plaster  are 
beneficial.  Gummy  ulceration,  especially  when  situated  in  the  mouth  or 
pharynx,  is  hest  treated  by  the  application  of  benzoin  co.  Iodoform  is  also 
quite  effectual,  but  unpleasant,  for  most  patients  do  not  like  to  have  such 
an  odorous  application  in  so  close  proximity  to  their  nasal  and  digestive 
organs. 

The  following  formulas  will  be  found  quite  effectual  in  lesions  of  the 
throat  and  nose: — 

IJ  lodoformi, 

Camphorse   of  each  3iij. 

Morphise    gr.  ij- 

Pulv.   acacise 3ij. 

Ac.  tannic! gr.  x. 

Bismuthi  subnitratis 3iv. 

M.  Sig.:    Use  with  poAvder-blower. 

IJ  lodinii   puri gr.  xx. 

Kalii  iodidi gr.  Ix. 

Ac.   carbolici 3ss. 

Olei   eucalypti 3j. 

Boroglyceridi    3iij. 

Olei  menth.  pip • m.  x. 

Glycerin,   tannat q.  s.  ad  5j- 

M.     Sig.:    Apply  with  a  probang  or  camel's-hair  pencil. 


Iritis. — The  therapy  of  this  complication  of  syphilis  merits  special  con- 
sideration. In  this  disease  synechias  or  adhesions  form  ver}-  rapidl}"  and 
treatment  must  be  correspondingly  vigorous.  Where  possible,  the  responsi- 
bility should  be  divided  with  a  competent  ophthalmologist.  The  patient 
must  be  brought  under  mercury  as  rapidly  as  possible.  Either  hypodermic 
injections  of  the  mercuric  chlorid  or  minute  doses  of  calomel  frequently 
repeated  are  excellent  methods.  A  combination  of  inunction  and  internal 
administration  is  usually  effective.  Leeches  should  be  applied  to  the  tem- 
poral region,  and  cathartics  administered  to  secure  the  benefits  of  derivation 
and  local  depletion.  Either  hot  or  cold  apijlications  may  prove  beneficial. 
Most  important  of  all  is  dilatation  of  the  pupil  by  atropin.  A  solution  of 
from  4  to  8  grains  to  the  ounce  should  be  instilled  into  the  eye  several  times 
daily  until  dilatation  is  complete.  Weak  collyria  containing  bichlorid,  1  to 
20,000,  are  of  value. 

Concomitant  herpes  progenitalis  is  a  common  feature  of  syphilis,  oc- 
curring most  often  as  a  sequel.  As  stated  in  the  chapter  on  that  subject, 
the  author  regards  syphilis  as  a  frequent  cause  of  herpes.  The  oleate  and 
stearate  of  zinc  are  most  useful  applications  for  this  condition. 

Alopecia  is  greatly  benefited  by  the  following: — 


504  TEEATMEXT  OF  SYPHILIS. 

IJ  Hydrarg.  bichlor gr.  xx. 

Tr.  canthar §ss. 

Tr.  eapsici Bss. 

Glycerini   Bj- 

01.  ricini §j. 

Sp.  colognensis q.  s.  ad  Bviij. 

M.     Ft.  lotio. 

Sig. :    Eub  in  scalp  night  and  morning. 

IJ  Hydrarg.  biniodidi gr.  v. 

01.  verbenge m-  ij- 

Vaselini    §j. 

M.     Sig.:    Eub  well  into  the  scalp  at  bed-time. 

Treatment  of  Post-syphilitic  Leucoplasia. — In  deciding  the  question  of 
the  administration  of  antisyphilitic  treatment  in  leucoplasia,  considerable 
discrimination  is  necessary,  particularly  in  the  direction  of  estimating  as 
accurately  as  possible  its  relation  to  other  factors  than  syphilis.  It  will 
be  found  in  these  eases  that,  as  a  rule,  the  proper  course  of  antisyphilitic 
treatment  is  tonic  rather  than  radical.  Small  doses  of  mercury  bichlorid 
in  combination  with  tincture  of  cinchona-bark  are  much  safer,  particu- 
larly when  used  tentatively,  than  the  larger  doses  commonly  given  in  the 
earlier  and  more  active  periods  of  the  constitutional  infection.  It  may  be 
found  that  even  a  modern  amount  of  mercury  will  aggravate  the  lesions, 
and  under  such  circumstances  tonics  combined  with  the  mercurials  are  in- 
dicated. The  various  preparations  of  gold  are  useful  as  tonic  alteratives. 
The  liquor  arsenii  et  hydrargyri  bromidi  (Barclay)  is  an  excellent  prepara- 
tion. A  very  excellent  combination  of  alteratives  and  tonics  is  the  prepa- 
ration already  alluded  to — the  "three  chlorids"  (Henry).  The  dose  of  mer- 
cury in  this  preparation  is  so  small  that  its  specific  effect  may  be  disregarded, 
its  tonic  action  only  being  worthy  of  consideration.  Where  syphilis  is  be- 
lieved to  be  still  active,  the  author  inclines  to  inunctions  of  mercurial  oint- 
ment in  combination  with  large  and  increasing  doses  of  the  potassic  iodid 
given  with  great  caution,  particularly  as  regards  its  possible  debilitating 
effects.  It  Avill  be  found  that  the  majority  of  eases  are  anemic;  consequently 
all  radical  measures  of  treatment  should  be  carefully  guarded  by  the  judi- 
cious administration  of  nutrients  and  tonics.  Codliver-oil  in  combination 
with  a  pure  wine,  or  in  some  cases  a  moderate  amount  of  good  brandy  or 
whisky,  may  be  indicated.  There  are  occasions  where  alcoholics  are  highly 
advantageous,  even  in  active  syphilis.  This  is  too  often  disregarded.  The 
key-note  to  the  treatment  of  all  post-syphilitic  and  late  syphilitic  phe- 
nomena is,  in  many  cases,  the  administration  of  tonics  rather  than  vigorous 
antisyphilitic  treatment.  With  regard  to  the  use  of  tobacco  and  liquor — 
with  the  possible  exception  above  mentioned — there  should  be  even  less 
compromise  than  in  active  syphilis. 

With  reference  to  the  application  of  caustics  in  leucoplasia,  any  form 


TEEATMEISTT    OF   EAELT    STPHILITIO    NEUEOSES.  505 

of  caustic  that  is  not  immediately  and  thorouglily  destrnctive  simply  acts 
as  an  irritant  and  aggravates  the  pathologic  condition.  Superficial  caustics, 
such  as  the  nitrate  of  silver,  should  be  avoided.  Antiseptic  and  astringent 
washes  are  often  beneficial,  and  unless  used  in  too  great  strength  cannot 
possibly  be  harmful.  So  far  as  the  various  forms  of  antiseptics  and  astrin- 
gents are  concerned,  there  is  practically  little  choice  so  long  as  the  prin- 
ciples of  antisepsis  are  observed. 

From  clinical  experience,  some  of  which  has  been  of  a  rather  un- 
pleasant character,  the  author  has  concluded  that  in  obstinate  cases  of  leu- 
coplasia  and  those  that  recur  only  one  form  of  treatment  is  to  be  considered, 
and  that  a  most  radical  one — viz.:  free  excision  with  the  knife  or  scissors, 
followed  by  the  actual  cautery.  In  some  cases  the  author  has  used  the  actual 
cautery  alone.  There  should  be  no  hesitancy  in  the  thorough  application  of 
these  measures,  and  from  an  operative  stand-point  it  is  best  to  regard  these 
lesions  as  essentially  malignant,  complete  and  thorough  destruction  or  ex- 
cision being  consequently  indicated.  Half-hearted  destruction  or  excision 
is  worse  than  no  treatment  at  all,  as  is  true  of  genuine  malignant  neoplasms. 
Should  a  case  present  itself  in  the  transition  stage,  or  after  malignant  char- 
acters have  asserted  themselves,  the  lesion  should  be  treated  as  is  malignant 
disease  elsewhere.  There  is  a  question  in  the  author's  mind  whether  these 
cases  are  not  often  more  unfavorable  than  ordinary  malignant  disease  of  the 
mucous  membranes  of  the  mouth,  on  account  either  of  the  syphilitic  dys- 
crasia  or  the  post-syphilitic  anemia  and  debility  that  are  so  characteristic 
of  overdosed  patients. 

Treatment  of  Nerve  Disease  in  Early  Syphilis. — The  treatment  of  nerve 
disease  in  early  syphilis  is,  in  the  main,  that  of  the  specific  affection  upon 
which  it  depends;  hence  a  discussion  of  the  therapeutics  of  the  subject  may 
seem  superfluous.  There  are,  nevertheless,  numerous  practical  points  that 
demand  special  consideration. 

Prophylaxis  of  nerve  disorder  is  an  important  feature  in  all  cases  of 
syphilis.  It  is  to  be  remembered  that  the  nerve  disturbances  of  the  early 
period  are  not  only  important  per  se,  but  they  lay  the  foundation  for  later 
and  more  serious  disease.  It  is  well,  also,  to  bear  in  mind  that  certain 
factors  may  cause  nervous  disturbances  that  do  not  at  the  time  produce 
symptoms,  but  which  none  the  less  pave  the  way  for  serious  organic  nervous 
disease  at  a  later  period. 

Inasmuch  as  vasomotor  neurosis  is  probably  an  important  factor  in 
syphilitic  nerve  phenomena,  avoidance  of  all  causes  of  disturbance  of  the 
sympathetic  is  a  prime  indication.  Instability  of  vasomotor  equilibrium 
may  often  be  avoided.  Most  surgeons  are  aware  that  tobacco  and  liquor 
are  injurious  to  syphilitics,  but  comparatively  few  appreciate  other  than  em- 
piric reasons  therefor.  The  toxiceffect  of  these  drugs  upon  nerve-protoplasm 
and  the  sympathetic  ganglia  is  a  very  powerful  predisposing  factor  in 
brain  and  nerve  disease  in  syphilis.    By  them  the  foundation  is  often  laid 


506  TEEATJIEXT    OF    SYPHILIS. 

for  sulDsequent  disease  of  a  very  serious  or  even  fatal  character.  Mental 
"worr}^  or  overstrain,  mental  excitement,  and  sexual  excesses  constitute 
powerful  jDredisposing  causes — especially  of  cord  disease.  If  the  patient  be 
given  a  clear  understanding  of  the  true  reasons  for  abstinence  from  these 
injurious  factors,  he  is  likely  to  be  much  more  tractable.  In  cases  with  a 
distinct  neurojoathic  taint,  hereditary  or  otherwise^  the  points  that  have  been 
made  are  of  special  importance. 

The  curative  treatment  of  early  nerve  symptoms  is,  in  the  majority  of 
cases,  mercurial,  first,  last,  and  all  the  time;  but  there  are  certain  special 
therapeutic  features  that  are  of  greater  importance  than  in  other  phe- 
nomena of  S3q3hilis.  In  ordinary  syphilitic  phenomena  a  moderately-active 
course  of  treatment  usually  suffices,  and  a  few  days'  delay  in  getting  the 
disease  well  in  hand  is  of  no  consequence.  When  nerve-involvement  exists, 
however,  the  treatment  must  be  very  energetic,  indeed,  if  we  would  avoid 
irreparable  damage  to  delicate  and  important  nerve  and  brain  structures. 
The  problem  in  such  cases  is  how  to  get  the  patient  under  the  full  physio- 
logic effects  of  mercury  most  speedily.  As  a  rule,  internal  medication  alone 
cannot  be  relied  upon;  some  patients,  and  especially  those  Avith  nerve  phe- 
nomena, cannot  tolerate  the  internal  use  of  the  drug  at  all.  The  hypodermic 
method  is  much  quicker  and  more  reliable,  but  not  all  patients  will  submit 
to  it.  A  point  of  practical  value  is  the  fact  that  the  drug  acts  best  when 
applied  as  nearly  as  possible  to  the  location  of  the  nerve-implication.  Mer- 
curial inunctions  of  the  neck  and  scalp  are  most  efficacious  in  cerebral  dis- 
turbance, while  inunctions  of  the  region  of  the  spine  are  quite  effective  in 
cord  symptoms.  It  is  necessary  to  use  ordinary  inunctions  in  addition,  in 
order  that  a  sufficient  quantity  of  mercury  may  be  absorbed. 

Cases  are  met  with  in  which  mercury  seems  to  be  ineffectual  and  we 
are  compelled  to  rely  upon  the  iodids.  Such  cases  are  rare,  so  rare  that  some 
of  them,  perhapvS,  are  instances  in  Avhich  the  fault  lies,  not  with  the  mercury, 
but  with  the  manner  of  its  use.  While  the  mainstay  of  treatment  is  mer- 
cmy,  certain  drugs  are  of  great  value  as  adjuvants,  and,  aside  from  drugs, 
other  therapeutic  resources  may  be  resorted  to  with  advantage.  Stubborn 
cases  that  resist  ordinary  treatment  often  yield  readily  to  some  one  or  more 
of  the  adjuvant  methods.  As  regards  the  general  treatment  of  early  syph- 
ilitic nerve  disorder,  hot  baths,  free  water-drinking,  and  laxatives  are  of 
especial  value.     These  points  will  be  expatiated  upon  later. 

Counter-irritation  and  derivation  are  often  of  value  in  early  nerve 
syphilis.  Local  or  general  depletion  may  be  justifiable.  The  author  be- 
lieves that  in  some  cases  of  severe  head-symptoms  it  is  wise  to  apply  leeches 
to  the  mastoid  regions  or  even  perform  venesection.  The  same  rules  govern 
here  as  in  toxemias  of  other  kinds.  Electricity,  massage,  and  counter-irri- 
tation are  often  serviceable  in  subduing  obstinate  symptoms  tending  to 
chronicity. 

It  has  occurred  to  the  author  that  there  is  too   much  specializing 


GENEKAL.  MANAGEMENT    OF    SYPHILIS.'  507 

in  the  management  of  some  cases  of  syphilis.  Mercury  and  potassic  iodid 
are,  i.t  is  true,  the  only  specifics  for  the  disease;  but  this  does  not  warrant 
neglect  of  certain  remedies  that  are  of  great  value  for  the  relief  of  certain 
special  conditions.  Gold  is  especially  valuable  in  nerve  symptoms  as  ,a  tonic 
and  alterative.  Barclay's  and  Clark's  formulas  have  already  been  mentioned 
as  the  only  reliable  preparations  of  gold.  G-old  seems  to  have  a  special  effect 
in  preventing,  and,  to  a  certain  extent,  removing,  sclerotic  changes  in  the 
tissues  affected  by  the  syphilitic  neoplasm.  The  bromid  in  the  Barclay  com- 
binations may  be  of  service  in  correcting  the  vasomotor  perturbations  that 
probably  exist  in  early  nerve  syphilis. 

In  addition  to  the  specific  and  eliminant  treatment  for  early  nerve 
syphilis,  nervine  tonics  and  remedies  to  correct  anemia  may  come  into  play. 
Of  the  preparations  of  iron,  ferratin,  subcarbonate  of  iron,  reduced  iron, 
and  the  new  preparation  known  as  peptomangan  are  best. 

Cases  occasionally  arise  in  which  a  tonic  stimulant  becomes  necessary. 
Under  such  circumstances,  the  wine  and  fluid  extract  of  coca  are  of  special 
service. 

The  question  now  arises:  How  long  shall  the  treatment  of  nerve-lesions 
be  continued?  As  a  matter  of  principle,  the  author  believes  that  any  course 
of  treatment  of  syphilis  of  less  than  three  years'  duration  is  open  to  criti- 
cism, and  is  especially  inclined  to  be  dogmatic  in  regard  to  cases  presenting 
early  nerve  or  brain  symptoms.  The  author  has  been  much  impressed  by 
some  of  Hutchinson's  cases  of  nerve  syphilis.  It  would  appear  that  some 
of  them  might  have  been  avoided  by  proper  treatment.  Hutchinson's  treat- 
ment is  largely  symptomatic;  if  at  the  end  of  a  six  months'  course  the 
symptoms  have  disappeared,  treatment  is  stoj)ped,  to  be  resumed  only  on 
the  occurrence  of  symptoms.  Steady  systematic  treatment  by  mercury, 
iodids,  and  gold  is  the  sole  assurance  of  safety  for  the  syphilitic.  After 
many  years  of  experience  with  this  plan  in  syphilis  the  author  has  rarely 
seen  visceral,  bone,  nerve,  or  brain  involvement  in  cases  in  which  instruc- 
tions have  been  carried  out  to  the  letter. 

Geneeal  Management  of  Syphilis. — In  his  attempt  to  cure  an  un- 
questionably specific  disease  by  specific  medication  the  practitioner  is  very 
apt  to  overlook  certain  essentials  in  the  general  management  of  syphilis  that 
are  fully  as  important  as  the  use  of  remedies  which  are  considered  anti- 
syphilitic  per  se.  Indeed,  it  is  questionable  whether  philosophic  general 
management  does  not  often  accomplish  more  in  the  long  run  than  our  mer- 
curials and  iodids.  This  much  may,  at  least,  be  said,  viz.:  that,  while 
specific  medication  alone  may  cure  syphilis,  good  general  management,  plus 
specific  medication,  is  almost  certain  to  do  so.  If  the  surgeon  were  com- 
pelled to  rely  upon  one  plan  alone  in  the  treatment  of  the  average  case, 
judicious  general  management  would  be  most  likely  to  achieve  success. 

Ckire  of  the  Moufli  and  Teeth. — As  a  matter  of  clinical  observation,  it 
is  safe  to  assert  that  the  patient  who  takes  the  best  care  of  his  mouth  and 


508  TEEATMEXT  OF  SYPHILIS. 

teeth  is  least  dangerous  to  those  about  him.  The  question  of  tobacco-using 
is  very  pertinent  in  this  connection,  for  it  is  the  patient  who  smokes  or 
chews  tliat  is  most  likely  to  have  outcroppings  of  the  disease  in  the  mouth 
and  throat.  In  addition  to  its  local  irritating  action,  tobacco  unquestion- 
ably has  a  detrimental  constitutional  eifect  that  impairs  the  efficacy  of 
medicines.  Patients  with  bad  teeth  and  gums  should  have  their  mouths  put 
in  order  by  a  first-class  dentist  at  the  outset  of  treatment.  The  importance 
of  preventing  or  lessening  the  severity  and  duration  of  lesions  of  the  lips, 
mucous  as]Dect  of  the  cheeks,  and  tongue  is  not  only  important  as  bearing 
on  the  prevention  of  infection  of  innocent  persons,  but  also  with  reference 
to  the  proplwlaxis  of  the  post-syphilitic  mucous  lesions  described  in  the 
jDreceding  chapter. 

Dietetic  Management. — The  regulation  of  the  diet  of  syphilitic  patients 
is  a  very  simple  matter  so  far  as  foodstuffs  are  concerned.  The  author's 
advice  to  patients  is  usually  to  eat  the  best  they  can  get  and  all  they  want 
of  it,  with  this  qualification,  viz.:  that  they  abstain  from  sweets  and  acids 
during  the  administration  of  mercury,  and  whenever  the  mouth,  tongue,  or 
throat  is  affected  by  ulcers,  mucous  patches,  or  inflammation.  In  the  event 
of  these  lesions'  appearing,  spices  should  also  be  interdicted,  and  it  may  be- 
come necessary  to  prescribe  a  fluid  diet.  In  case  of  mercurial  stomatitis  the 
latter  is  absolutely  essential,  and  milk  should  usually  be  relied  on  as  the 
most  nourishing  and  acceptable  form  of  aliment. 

The  question  of  alcoholics  is  the  most  important  point  of  all.  There 
should  be  no  compromise  in  this  matter.  Liquors,  both  vinous  and  malt, 
should  be  absolutely  forbidden,  excepting  when  ordered  by  the  physician  to 
combat  some  emergency  or  to  counteract  extreme  debility.  Patients  often 
say:  "T\"ell,  but  there's  Tom  A.,  who  had  syphilis;  Dr.  X.  treated  him  and 
allowed  him  to  drink  and  smoke  all  the  time,  and  he  got  along  finely."  We 
might  say  to  this  patient:  "The  procession  of  veterans  on  Decoration  Day 
would  indicate  to  the  superficial  observer  that  war  is  not  invariably  fatal; 
yet  the  little  white  head-stones  on  the  sunny  slopes  of  the  southern  hills 
show  that  war  cannot  be  recommended  as  a  safe  and  pleasant  occupation" 
— or  words  to  that  effect.  That  Tom  A.  has  been  shot  at  and  missed  is  no 
criterion  for  the  management  of  the  case  in  hand.  Again,  there  is  always 
the  possibility  that  Dr.  X.  was  just  as  ignorant  or  as  mercenary  in  Tom  A.'s 
case  as  some  physicians  are  in  those  six-month  "cures"  of  so-called  syphilis 
with  which  the  conscientious  surgeon  is  only  too  familiar. 

Eeverting  again  to  AVillard  Parker's  aphorism,  liquor  is  one  of  the 
"devils"  of  which  the  syphilitic  patient  must  rid  himself  if  he  dfesires  to 
give  his  physician  a  fair  chance  to  cure  him. 

Exposure  to  Cold  and  Wet. — This  is  a  point  of  practical  import.  The 
syphilitic  is  necessarily  more  sensitive  to  changes  of  weather  and  exposure 
to  the  elements  than  a  healthy  person.  There  is  no  doubt  that  treatment, 
embracing,  as  it  does,  mercurials,  the  iodids,  and  hot  baths,  tends  to  increase 


GENERAL    MANAGEMENT    OF    SYPHILIS.  509 

this  predisposition  to  cold-taking,  rlienmatoid  pains,  etc.  Patients  of  a 
rheumatic  or  gouty  diathesis  are  not  always  easy  to  treat  when  syphilitic. 
When  the  patient  is  debilitated  from  any  cause,  whether  connected  with  the 
syphilis  per  se  or  not,  great  caution  is  necessary.  The  skin  must  be  kept 
warm,  and  exposure  to  wet  weather  avoided  so  far  as  possible.  The  adminis- 
tration of  codliver-oil  in  combination  with  iron,  quinin,  or  the  hypophos- 
phites,  is  often  of  great  service  in  warding  off  hypersensitiveness  to  baro- 
metric changes  and  in  correcting  debility.  Such  remedies  are  a  sine  qua  non 
where  the  patient  is  strumous. 

The  Correction  of  Pernicious  Ideas  of  the  Duration  and  Treatment  of 
Syphilis. — It  may  be  necessary  to  disabuse  the  patient^s  mind  of  one  or  more 
of  several  fallacies,  viz.:  1.  That  syphilis  can  be  antidoted  in  a  short  time 
by  specific  medication  or  a  sojourn  at  the  Hot  Springs.  2.  That  the  disease 
is  incurable.    3.  That  mercury  is  necessarily  injurious. 

The  nature  and  natural  course  of  infectious  diseases  should  be  ex- 
plained, and  the  patient  impressed  with  the  similarity  of  syphilis  to  the 
commoner  eruptive  diseases,  such  as  small-pox,  measles,  etc.  He  should  be 
made  to  plainly  understand  that  syphilis  may  be  successfully  conducted 
through  its  natural  course  to  a  cure;  that  there  is  no  royal  road  to  health; 
that  attempts  to  "stamp  out"  the  disease  may  stamp  out  the  patient,  but 
never  the  syphilis;  that,  while  syphilis  can  be  cured  in  the  large  majority 
of  cases,  it  can  only  be  cured  by  careful  systematic  treatment,  usually  for 
three  years,  and  in  severe  cases  a  still  longer  time. 

The  patient  usually  requires  enlightenment  on  the  mercury  question. 
He  should  be  assured  that  the  attempt  to  cure  syphilis  without  mercury  is 
equivalent  to  an  attempt  to  play  Hamlet  without  Hamlet.  He  should  also 
be  informed  that  mercurj^,  properly  used,  is  rarely,  if  ever,  injurious.  Its 
abuse  may  injure;  its  proper  use,  almost  never.  Mercury  is  less  likely  to 
play  us  false  than  almost  any  drug  of  recognized  therapeutic  potency,  yet 
nobody  condemns  the  proper  use  of  other  drugs  as  remedies.  Those  who 
condemn  mercury  have  never  learned  to  use  it  properly.  Patients  should 
also  understand  that  the  cases  of  alleged  mercurial  poisoning  that  are  harped 
upon  by  an  ignorant  laity  and  still  more  culpably  ignorant  physicians  are, 
as  a  rule,  either  due  to  a  misapplication  of  the  drug  or,  what  is  more  likely, 
are  really  neglected  cases  of  syphilis  that  are  suffering  for  want  of  mercury. 
So-called  "mercurial  lesions"  are  frequently  cured  by  tonic  doses  of  the 
bichlorid.  It  has  already  been  admitted  that  mercury  may  do  damage  if 
injudiciously  used,  but  its  evil  effects  can  be  early  detected  and  readily 
controlled. 

Hydrotherapy  in  Syphilis. — The  free  use  of  water,  internally  and  exter- 
nally, is  nowhere  productive  of  more  benefit  than  in  the  general  manage- 
ment of  syphilis.  As  an  adjuvant  to  internal  treatment,  hot  baths  especially 
are  invaluable.  The  Turkish  or  Eussian  bath  once  or  twice  weekly  has  an 
excellent  general  as  well  as  local  effect,  and  where  possible  should  be  pre- 


510  TEEATMEXT  OF  SYPHILIS. 

scribed  in  all  cases  of  syphilis.    Hot  baths — and  especially  Turkish  baths — 
have  several  important  effects  in  syphilis.     These  are,  briefly: — 

1.  Stimulation  of  the  nutrition  of  the  skin,  thus  rendering  eruptions 
less  likely  to  occur. 

2.  Elimination  of  peccant  materials,  and  of  mercury  itself,  thus  pre- 
venting saturation  of  the  system  with  the  drug,  and  assisting  the  system 
in  throwing  off  the  products  of  retrograde  metamorphosis  of  syphilitic 
neoplasia. 

3.  Increase  of  retrograde  tissue-metamorphosis,  thus  hastening  resolu- 
tion of  syphilitic  deposits. 

4.  A  general  tonic  effect. 

5.  Followed  by  the  cold  shower,  they  have  a  marked  tonic  effect  upon 
the  skin,  lessening  the  danger  of  cold-taking. 

A  careful  survey  of  the  results  and  methods  of  Hot  Springs  treatment 
has  convinced  the  majority  of  syphilographers  that  it  is  the  hot  baths, 
per  se,  and  not  some  mysterious  property  which  the  waters  contain,  that  is 
efficacious  in  assisting  the  cure  of  syphilis  at  this  famous  resort.  Anything 
that  favors  rapid  tissue-metamorphosis  and  hastens  elimination  of  waste- 
products  benefits  syphilis.  In  this  respect  the  hot  baths  at  the  springs  may 
be  imitated  by  baths  that  can  be  obtained  at  home — at  least  in  our  large 
cities.  It  is  the  author's  custom  to  advise  Turkish  baths  throughout  the 
entire  course  of  treatment  for  syphilis.  These  baths  should  be  crowded  to 
the  point  of  tolerance.  This  varies  with  the  resistancy  of  the  patient. 
There  are  few  patients,  indeed,  who  cannot  stand  two  baths  per  week. 
Special  courses  of  rubbing  with  mercury  and  daily  Turkish  baths  for  three 
or  more  weeks  are  often  very  useful.  By  the  exercise  of  a  little  care  patients 
may  be  made  to  bear  the  frequent  baths  very  Avell.  A  useful  practical 
point  is  that  patients  do  best  who  drink  freely  of  very  hot  water  while  in 
the  bath. 

The  question  of  the  advisability  of  a  sojourn  at  Hot  Springs  often 
arises  during  the  course  of  treatment  of  syphilis.  The  laity  entertains  a 
very  fallacious  notion  of  the  merits  of  the  waters  of  this  resort.  There  is 
a  belief  on  the  part  of  many  patients  that  syphilis  cannot  be  ciired  save 
by  a  trip  to  the  springs.  There  seems  to  be  complete  ignorance  on  the 
part  of  most  laymen  of  the  fact  that  the  usual  course  of  treatment  at  the 
springs  comprises  large  doses  of  mercury  and  potassic  iodid,  the  baths  being 
a  secondary  consideration.  The  author  has  had  occasion  to  send  a  very  small 
proportion  of  syphilitics  to  Hot  Springs,  and  these  were  not  sent  because 
of  faith  in  any  specifically  curative  property  of  the  wateres.  The  cases  in 
which  the  author  advises  a  sojourn  at  the  springs  are: — 

1.  Patients  who  can  well  afford  the  time  and  expense  and  who  accept 
the  trip  as  a  therapeutic  luxury.  2.  Patients  who  wish  to  be  away  from 
home  while  undergoing  vigorous  treatment  for  palpably  disfiguring  lesions. 
3.  Patients  who  are  run  down  in  health  and  upon  whom  remedies  no  longer 


THE   HOT    SPRINGS    FOR    SYPHILIS.  511 

act  energetically.  To  such  as  these  the  reinvigoration  incidental  to  a  trip 
to  the  springs,  with  its  freedom  from  care  and  worry,  the  rejuvenating 
effects  of  the  hot  baths,  and  the  change  of  climate  are  often  of  great  value. 
4.  Patients  who  cannot  tolerate  either  mercurials  or  iodids  save  in  a  Avarm 
climate  and  with  freedom  from  business  cares.  It  will  thus  be  seen  that  the 
eases  in  which  a  sojourn  at  the  springs  is  really  necessary  are  relatively  few; 
the  necessity  being  essentially  the  same  in  most'  eases  as  in  other  debili- 
tating diseases. 

When  a  sojourn  at  the  springs  has  been  decided  on,  there  are  several 
points  that  should  be  impressed  upon  the  patient's  mind,  viz.:  1.  The  fact 
that  a  sojourn  at  the  springs  does  not  cure  syphilis  nor  lessen  the  duration 
of  treatment.  2.  That  the  springs  are  of  little  value  unless  careful  treat- 
ment at  the  hands  of  some  capable  physician  at  that  resort  is  also  under- 
taken. In  the  selection  of  a  physician  the  patient  should  be  guided  by  his 
medical  attendant  at  home.  It  must  be  confessed,  however,  that  this  is  a 
matter  that  is  difficult  of  control.  No  matter  how  carefully  the  patient  may 
be  directed  to  a  reputable  physician  at  the  springs,  he  is  quite  likely  to  give 
ear  to  the  wily  drummer  of  the  still  wilier  quack.  Of  the  patients  referred 
directly  to  skillful  physicians  at  the  springs,  about  one  in  ten  arrive  at  the 
designated  office.  But  we  cannot  cure  our  patients  of  foolishness  and 
mental  vacillation. 

The  one  great  objection  to  be  urged  against  the  springs  is  that  the 
patient  may  be  led  to  believe  that  he  is  cured  by  a  few  weeks'  sojourn 
thereat,  and  consequently  neglect  himself  on  his  return.  If,  however,  he 
has  consulted  a  reputable  physician  at  the  springs,  he  will  be  informed  of 
the  necessity  of  returning  to  his  regular  medical  attendant  for  a  continu- 
ation of  treatment.  The  charlatan,  on  the  other  hand,  simply  advises  the 
patient  to  return  to  the  springs  and  be  ''cured"  when  he  has  "another  at- 
tack of  syphilis." 

Such  dishonesty — or,  perchance,  ignorance — has  been  responsible  for 
a  large  number  of  uncured  and  incurable  cases  of  syphilis. 

One  of  the  fairest  dissertations  upon  the  therapeutic  value  of  the  Hot 
Springs  is  an  article  by  Dr.  J.  M.  Keller,'-  whose  experience  at  that  resort  has 
certainly  been  extensive  enough  to  give  authority  to  his  opinion.  He  says 
as  follows: — 

.  .  .  If  asked — "Does  the  water  of  itself  cure  syphilis?"' — I  answer,  posi- 
tively, "iSTo!"  If  asked  how  it  acts,  the  answer  is  simply  that,  by  its  powerful 
eliminative  and  diaphoretic  power,  the  patient  is  enabled  to  take,  if  necessary,  ten- 
fold more  mercury  and  potash  than  he  could  possibly  take  without  its  aid;  more 
than  he  could  with  the  help  of  any  artificially-heated  bath  I  have  ever  had  experi- 
ence with.  Of  the  naturally-heated  water  patients  can  drink  ad  liMUim,  for  it  has 
never  been  known   to   produce  nausea.     A  bath  at   a   temperature   of  98°   F.,  with 


^  J.  M.  Keller :    "Hot  Springs  as  a  Health  Resort,"  St.  Louis  Medical  and  Sur- 
gical Journal,  August,  1879. 


512  TREATMENT    OF    SYPHILIS. 

copious  draughts  of  the  water,  -will  produce  more  profuse  diaphoresis  than  tlie  arti- 
ficially-heated bath  will  at  110°. 

The  daily  assertions,  and  many  circular  statements,  that  syphilis,  under  any 
plan  of  treatment  here,  can  be  cured  in  four  or  six  weeks  are  all  false,  and  have 
done  much  to  ruin  the  reputation  which  the  springs  actually  deserve.  It  is  useless 
for  anyone  to  come  here  under  any  such  assurances  expecting  to  be  cured.  They 
will  surely  be  disappointed.  They  may,  and  generally  do,  find  all  outward  or  visible 
manifestations  gone  after  six-  weeks'  active  medication  and  bathing,  and  may  be  per- 
suaded that  the  disease  has  been  eradicated,  never  to  return;  but  the  delusion 
seldom  lasts  very  long,  if  they  end  their  visit  after  that  length  of  time.  As  a  rule, 
it  is  useless  for  syphilitics  to  come  here  unless  they  come  detennined  to  stay  at  least 
ten  weeks.  Then,  if  they  have  been  properly  treated,  1  am  satisfied  they  can  go  home 
with  a  pretty  strong  assurance  of  the  disease's  being  cured  by  continual  treatment 
for  a  year  or  two. 

Dr.  Keller's  remark,  that  syphilitics  treating  at  the  springs  "may,  and 
generally  do,  find  all  outward  or  visible  manifestations  gone  after  six  iveehs' 
active  medication  and  lathing,"  is  very  suggestive  in  view  of  the  fact  that 
the  same  result  may  be  attained,  upon  the  average,  by  the  proper  use  of 
mercury  alone.  The  cases  of  secondary  symptoms  that  do  not  yield  within 
six  weeks  are  relatively  rare.  Taken  all  in  all,  the  claims  of  the  springs  to 
a  specific  influence  in  syphilis  do  not  seem  to  be  worth  serious  consideration. 

Laying  aside  ,the  alleged  specific  action  of  the  Hot  Springs  in  syphilis, 
however,  the  author  believes  that  the  water  has  properties  that  are  not 
possessed  by  ordinary  hot  water.  Wherein  the  naturally-heated  hot  water 
difEers  from  that  which  is  artificially  heated  does  not  seem  to  have  been 
satisfactorily  demonstrated.  That  the  former  is  "charged  with  electricity" 
has  been  claimed,  but  the  proofs  of  this  electric  property  seem  rather  vague, 
judging  from  the  statements  of  jshysicians  at  the  springs.  This  much  is 
certain,  however, — and  the  author  has  verified  this  point  by  experiment 
upon  his  own  person — one's  experience  with  ordinary  hot  baths  is  not  a 
safe  criterion  for  guidance  in  taking  the  baths  at  Hot  Springs.  An  ordi- 
nary hot  bath  at  110°  F.  may  be  taken  daily  for  some  time  without  dele- 
terious effects;  not  so  the  baths  at  the  springs.  They  will  be  found  very 
depressing  when  taken  frequently  at  more  than  a  moderate  temperature — 
say  96°  to  98°  F.  How  much  the  climatic  and  atmospheric  conditions  at 
the  springs  have  to  do  with  the  peculiar  effects  of  the  baths  the  author  is 
not  prepared  to  state.  It  is  safe  to  say,  however,  that  they  should  never  be 
taken  save  under  competent  medical  supervision. 

In  studying  the  various  classes  of  cases  that  go  to  the  springs  for  treat- 
ment the  author  has  been  struck  by  the  large  number  of  unsuitable  cases 
that  wend  their  way  to  this  resort  for  treatment.  Hot  Springs  appears  to 
be  the  Mecca  of  incurables.  It  is  high  time  the  public  was  given  to  under- 
stand that  the  springs  is  not  a  cure-all.  Much  harm  results  from  the  pre- 
vailing ignorance  upon  this  point,  and  no  little  damage  is  done  to  the  rep- 
utable members  of  the  profession  at  the  springs  by  improperly  selected 


aBISTEEAL    CONCLirSIONS.  513 

cases,  especially  when  such  cases  happen  to  fall  in  the  hands  of  the  qnacks 
at  that  resort,  as  is  so  often  the  case. 

SypJiilo phobia. — There  is  an  nnfortunate  and  illogical  tendency  on  the 
part  of  both  patients  and  physicians  to  regard  one  who  is  once  syphilitic  as 
always  syphilitic,  and  to  pronounce  every  ailment  during  his  after-life  syphi- 
litic. It  must  be  remembered  that  the  syphilitic  patient  is  in  nowise  in- 
sured against  other  ailments.  Eheumatoid  pains,  sore  throat,  acne,  etc., 
may  mean  no  more  in  him  than  in  any  other  individual.  The  physician 
should  assure  his  patient  that  every  little  pimple  or  transitory  pain  does  not 
necessarily  mean  that  his  syphilis  is  not  cured. 

One  of  the  most  frequent  trailers  in  the  wake  of  syphilis  is  herpes  pro- 
genitalis.  This  is  a  trophoneurotic  effect  of  syphilis  oftentimes,  but  does 
not  mean  syphilis  any  more  than  it  does  any  other  debilitating  disease. 
But  the  little  ulcers  may  annoy  the  patient  greatly,  and  deceive  the  phy- 
sician; hence  they  must  be  explained.  Similar  herpetic  ulcers  often  appear 
in  the  mouth  and  may  be  mistaken  for  mucous  patches.  Sometimes  these 
ulcers  are  due  to  mercury  or  the  iodids;  sometimes  they  are  a  pure  neurosis. 

A  sore  throat  is  very  often  experienced  by  syphilitics  long  after  the 
disease  proper  has  passed  away.  This  is  also  in  many  cases  a  purely  nervous 
derangement — or  at  least  nervous  perturbation  is  at  the  bottom  of  it.  Often, 
too,  it  is  gouty  or  rheumatic. 

GENEEAL    CONCLUSIONS. 

1.  The  cure  of  syphilis  should  not  be  attempted  by  specific  medication 
alone,  but  certain  general  principles  of  management  should  be  applied. 

2.  IsTo  attempt  should  be  made  to  destroy  the  chancre.  Irritants  should 
be  avoided,  and  the  patient  should  be  assured  that  there  is  little  or  no  danger 
of  serious  local  destruction.  The  time-element  and  the  necessity  for  caution 
in  diagnosis  should  be  remembered. 

3.  Treatment  should  not  be  begun  until  a  positive  diagnosis  has  been 
made,  excepting  in  the  rare  cases  where  internal  treatment  may  be  neces- 
sary to  clear  up  the  doubt. 

4.  There  should  be  little  restriction  in  diet.  All  forms  of  liquor  and 
tobacco  should  be  forbidden. 

5.  The  patient  should  understand  that  the  natural  course  of  syphilis 
is  from  eighteen  months  to  three  years.  The  disease  cannot  be  cured  in 
less  time,  and  on  the  average  it  requires  three  years'  treatment. 

6.  He  should  be  informed  that  mercury,  properly  used,  is  absolutely 
necessary  in  the  majority  of  cases  of  syphilis,  and  that  no  case  is  safe  with- 
out it.    Mercury  is  neither  pernicious  nor  dangerous  when  properly  used. 

7.  Most  of  the  so-called  bad  effects  of  mercury  are  really  cases  of  syph- 
ilis that  have  not  had  enough  mercury. 

8.  Hot  baths  are  necessary  throughout  the  entire  course  of  treatment; 
Turkish  baths,  if  they  can  be  had;  plain  hot  baths  if  the  former  cannot. 


514  TEEATMENT    OF    SYPHILIS. 

9.  The  Hot  Springs  are  not  necessary  in  the  management  of  syphilis. 
They  may  be  of  assistance  in  rare  cases,  but  do  not  shorten  the  duration  of 
syphilis  a  single  day,  nor  can  they  be  depended  on  for  a  cure.  They  never 
lessen  the  necessity  for  medical  treatment. 

10.  Lesions  in  syphilitic  patients  or  those  who  have  once  had  syphilis 
should  be  diagnosed  and  treated  upon  their  merits.  "Once  syphilitic,  every- 
thing syphilitic"  is  fallacious  reasoning.  Patients  formerly  syphilitic  may 
have  non-specific- lesions,  as  may  anyone  else. 

11.  The  laity  should  be  given  to  understand  that  syphilis,  properly 
treated,  is  not  only  not  incurable,  but  is  one  of  the  most  curable  of  all  dis- 
eases, providing  it  be  given  the  same  chance  for  a  cure  as  is  given  other 
chronic  diseases  of  equal  importance.  This  means  steady  and  uninterrupted 
treatment  for  many  months. 

The  treatment  should  comprise,  in  the  main,  mercury  and  the  iodids. 

12.  Careful  consideration  should  be  given  to  complicating  conditions 
and  to  certain  symptoms  in  the  period  of  sequels  that  can  in  no  sense  be 
regarded  as  syphilitic.  In  short,  due  regard  should  be  given  the  patient 
as  well  as  his  syphilis. 

13.  Matrimony  should  be  interdicted  until  at  least  three  years  after 
infection.  It  may  then  be  permitted,  providing  the  patient  has  had  no 
symptoms  of  syphilis  for  at  least  eighteen  months.  In  women  the  period 
of  probation  should  be  longer.  In  any  event,  matrimony  should  not  be 
sanctioned  unless  the  case  has  been  carefully  treated  for  the  proper  length 
of  time.  As  there  is  always  a  certain  element  of  danger  that  cannot  be  esti- 
mated, even  approximately,  the  patient  should  assume  all  responsibility  save 
that  of  a  reasonable  probability  of  safety.  This,  and  nothing  further, 
should  be  assumed  by  tbe  physician. 


PART  VL 

DISEASES  AFFECTING  SEXUAL  PHYSIOLOGY. 


CHAPTER  XXL 

Abeeeant  and  Impeefect  Diffeeentiation  of  Sex. 

The'  relation  of  physical  deformities  of  congenital  origin  involving 
the  sexual  organs  to  abnormalities  and  imperfections  of  the  sexual  function 
is  a  most  important  one.  The  subjects  of  physically  aberrant  sexual  differ- 
entiation are  more  numerous  than  is  generally  believed;  fortunately,  how- 
ever, the  majority  of  cases  are  either  slightly  marked  or  of  but  little  prac- 
tical importance  as  regards  their  physiologic  and  social  status. 

Certain  marked  cases  of  physical  aberration  of  sexual  structure  have 
always  been  of  vital  importance  to  medical  jurists.  Hermaphroditism,  so- 
called,  has  received  considerable  attention  from  authorities  on  medical 
jurisprudence.  In  England,  where  the  law  of  primogeniture  prevails,  the 
male  is  relatively  so  important  a  factor  in  the  body  social  that  the  legal 
traditions  upon  the  subject  of  hermaphroditism  have  been  much  more  en- 
during and  important  than  elsewhere. 

As  our  knowledge  of  physiology  and  morphology  has  advanced,  how- 
ever, the  so-called  hermaphrodite  has  not  only  decreased  in  frequency  in  all 
social  systems,  but  is  a  much  less  important  factor  in  jurisprudence.  The 
most  important  features  of  such  cases  at  the  present  time  are  the  questions 
of:  1.  Impotency  and  sterility  in  both  sexes.  2.  Sexual  perversion  and 
inversion  or  other  psychopathies  of  a  sexual  type. 

That  the  evils  resulting  from  aberrations  of  structure  of  the  sexual 
organs  produce  mechanic  and  functional  obstacles  to  procreation  is  in  no- 
wise remarkable  and  is  sufficiently  well  understood. 

The  psychosexual  aspect  of  the  question  is  not,  however,  so  fully  and 
intelligently  comprehended  as  it  should  be.  The  term  hermaphroditism  has 
been  applied  in  a  loose  and  unscientific  fashion,  the  physical  conformation 
of  the  subjects  being  accepted  as  the  chief  factor  in  diagnosis.  Hermaphro- 
ditism literally  implies  a  mingling  of  the  physical  and  functional  qualities 
of  both  sexes.  The  crucial  test  as  now  accepted  is  the  existence  of  a  more 
or  less  perfectly  formed  testicle  and  ovary  in  the  same  individual.  Even 
from  this  stand-point  the  existence  of  true  hermaphroditism  is  open  to  seri- 
ous question.  If  hermaphroditism  be  accepted  as  implying  the  performance 
of  the  male  or  female  function  at  will,  such  a  condition  cannot  possibly  exist 

(515) 


516 


ABEEEANT   AND   IMPEEFECT    DIFFEEENTIATION    OF    SEX. 


in  view  of  the  fact  that  the  sexual  function  does  not  begin  and  end  with 
the  act  of  sexual  congress,  procreation  being  necessary  to  its  complete  ful- 
fillment. The  so-called  hermaphrodite  is  sterile — fortunately  for  society — 
and,  so  far  as  procreation  is  concerned,  cannot  functionate  as  either  male 
or  female.     The  author  is  of  opinion  that,  while  pseudohermaphroditism 


Fig.  120. — Aberrant  psychosexual  differentiation  Avith  imperfect  physical  dif- 
ferentiation.   Sexual  organs  of  normal  form,  but  undeveloped.     (Author's 


is  by  no  means  rare,  true  hermaphroditism  does  not,  and  from  biologic 
reasoning,  cannot,  exist. 

Although  in  most  cases  of  pseudohermaphroditism  it  is  possible  to 
classify  the  subject  as  either  male  or  female  with  greater  or  less  ease,  it 


DIFFICULTIES    IN    DIAGNOSIS.  517 

must,  nevertheless,  be  acknowledged  that  cases  occasionally  occur  in  which 
the  differential  diagnosis  demands  the  highest  degree  of  diagnostic  skill.  A 
case  coming  under  'the  observation  successively  of  Guyon  and  Fournier 
pointedly  illustrates  this.  These  distinguished  gentlemen  rendered  lengthy 
and  diametrically-opposed  opinions  as  to  the  sex  of  the  subject. 

Cases  occasionally  occur  in  which  a  differential  diagnosis  is  impossible 
until  the  age  of  puberty,  when  certain  sexual  attributes — menstruation,  the 
growth  of  beard,  changing  voice,  etc.,  as  the  case  may  be — decide  the  ques- 
tion of  sex.    In  very  rare  instances  the  sex  cannot  be  decided  during  life. 

In  some  of  the  eases  of  alleged  hermaphroditism  the  subject  not  only 
does  not  present  what  can  justly  be  termed  an  admixture  of  male  and 
female  organs,  but  is  practically  a  neuter,  being  without  either  desire  or 
capacity  to  perform  the  functions  of  either  sex.  When,  however,  the  subject 
of  general  and  local  malformation  is  also  the  subject  of  sexual  perversion, 
observation  of  the  ease  may  indicate  an  apparent  commingling  of  the  func- 
tional capacity.  A  case  coming  under  the  author's  observation  aptly  illus- 
trates this.  The  case  was  that  of  a  mulatto  cook  to  whose  case  attention 
was  called  by  some  of  the  lads  of  the  neighborhood,  who  came  for  relief 
from  typic  gonorrhea,  which  they  claimed  they  had  contracted  from  him. 
Investigation  proved  the  proof  of  the  boys'  story.  This  hypospadiac  male 
had  contracted  the  disease  from  a  female  in  the  normal  manner,  and.  sub- 
sequently, performing  the  passive  role  in  the  sexual  act,  had  given  the 
disease  to  the  lads. 

A  case  illustrating  the  difficulties  of  diagnosis  in  so-called  hermaphrodi- 
tism is  reported  by  Dr.  G.  E.  Glreen^: — 

Case. — A  housemaid,  aged  24,  had  symptoms  Avhich  seemed  to  point  to  retained 
menses.  She  was  five  feet  seven  inches  in  height,  of  dark  complexion,  and  anemic  in 
appearance.  For  several  years  she  had  been  in  domestic  service,  and  was  well  known 
to  the  doctor  personally.  On  examination,  the  external  genitals  appeared  to  be  those 
of  a  woman;  in  keeping  with  this  was  the  arrangement  of  the  pubic  hair,  while  there 
was  in  addition  considerable  mammary  development.  There  was  an  oval  body,  freely 
movable,  in  the  right  labium  and  a  similar  one  in  the  left.  On  separating  the  labia  a 
clitoris  was  found,  rather  larger  than  usual.  Below  this  was  a  small  opening,  which 
apparently  led  to  a  narrow  and  contracted  vagina.  Subsequent  examination,  however, 
under  ether,  revealed  a  very  different  state  of  things.  The  "swellings"  in  the  labia 
proved  to  be  testes;  the  labia  were  formed  by  a  splitting  of  the  scrotum  into  two 
halves.  At  the  bottom  of  the  "split"  the  "clitoris"  was  clearly  the  penis,  with  its  glans 
only  developed,  and  Avithout  the  corpus  spongiosum.  Upon  its  under  surface  there  was 
a  groove  which  led  backward  to  a  urethral  orifice,  into  which  a  silver  female  catheter 
easily  passed  into  the  bladder.  The  sex  of  this  "housemaid"  was  evidently,  therefore, 
male,  and  the  question  arose  what  was  to  be  done  under  the  circumstances.  The 
patient  was  anxious  to  continue  being  a  woman,  but  the  law  does  not  allow  a 
man  to  masquerade  in  woman's  clothes.  Dr.  Green  determined  that  the  difficulty 
would  be  met  if  he  were  to  remove  the  testicles  from  the  "labia."     This  was  aecord- 


^  Quarterly  Medical  Journal. 


518 


ABEERAXT   AXD    IMPEEFECT    DIFFEEENTIATION    OP    SEX. 


ingly  successfully  done,  and  no\y,  in  his  unsexed  condition,  the  man  has  resumed  his 
ordinary  occupation  of  that  of  a  "housemaid." 

Cases  of  pronounced  type  of  physical  sexnal  aberration  with  normal 
psychosexual  development  are  not  infrequent.  An  illustration  of  this 
coming  under  the  observation  of  C.  A.  AVheaton,  of  St.  Paul,  is  shown  in 
connection  with  the  subject  of  hyposj^adia  (Fig.  22). 

Aberrant  sexual  differentiation  may  not  involve  any  physical  defects 
of  the  sexual  organs;  it  may  be  purely  psychic,  and  dependent  upon  im- 
perfection differentiation  of  sexual  affinity.  That  there  is  an  essential  de- 
fect in  the  psychosexual  centers  of  the  cerebral  cortex  is  probable;   but,  if 


Fig.  121. — Pseudohermaphroditism  (aberrant  genitosexual  differentiation), 
showing  testes,  which  were  retained  within  the  pelvis.  Subject  was  a 
male. 

such  defect  exists,  it  is  too  occult  for  detection  by  any  known  method  of 
research.  Cases  of  psychicall3'-defective  sexual  differentiation  present  them- 
selves under  three  forms:  1.  Cases  Avith  normal  development  of  physical 
sexual  tj-pe,  both  general  and  local.  These  constitute  the  class  of  cases  in 
which  sexual  perversion  is  least  likely  to  be  suspected.  2.  Cases  of  normal 
general  physique,  but  defective  or  aberrant  development  of  the  genitals.  3. 
Cases  in  the  male  in  which  the  genitals  are  imperfectly  developed  and  the 
general  physique  effeminate. 

The  same  classification  applies  to  both  male  and  female.     The  author 
has,  however,  observed  homosexuality  oftener  among  neuropathic  females 


CLASSIFICATIOIS^    OF   IMPEEFECT    SEXUAL    DIFFEEENTIATIOX.  519 

of  an  iiltrafeminine  type  than  in  those  of  masculine  attributes.     It  is  ad- 
mitted that  this  is  probably  an  exceptional  experience. 

Sexual  affinity  has  been  held  to  be  a  form  of  hunger  which,  traced 
to  its  source,  is  merely  chemic  affinity.  If  this  be  true,  as  the  author 
believes  it  to  be,  imperfect  differentiation  of  sexuality  should  be  expected 
to  lead  to  reversional  peculiarities  manifested  by  sexual  perversions  of  vari- 
ous forms.  This  point  will  be  more  fully  discussed  in  the  next  chapter. 
The  point  that  the  author  desires  to  make  here  is  that  pederasts,  urnings, 
— a  term  applied  by  Caspar  to  individuals  having  "the  body  of  a  man  and 
the  soul  of  a  Avoman," — and  some  other  sexual  perverts  (inverts  especially) 
are  closely  akin  to  hypospadiacs  and  epispadiacs — so-called  hermaphrodites. 
Psychic  hermaphroditism  or  pseudohermaphroditism  may  be  quite  as  read- 
ily accepted  as  a  possibility  as  the  physical  type.  The  subjects  of  imperfect 
or  aberrant  sexual  differentiation  may  be  specially  classified  as  follows: — 

,     -|-         .f     .      j|-^        x-       C  Pederasts,  urnings,  subjects  of  bestiality  and  inverts; 
,.  ,,  1    ,  /affiTi     I  ^■^■!  individuals  with  a  sexual  affinity  for  their 

ity^  JithoTphysk^ri  defect,  ^  °^™  sex-homosexuality.     The  latter  is  called 

in  the  female  gynandry,  and,  in  the  male,  an- 
drogyny.    This  class  is  not  numerous. 


either  general  or  local. 


(«)   The  simplest  variety.     Genital  defects  partaking 
of  more  or  less  of  the  attributes  of  the  opposite 
sex,  with  normal  sexual  appetite. 
(&)   Genital  defects  of  similarly  atypic  conformation, 
2.    Defective — i.e.,   imper-     1  associated  with  perverted  sexual  appetite, 

feet  or  aberrant — differentia-    ^^    (c)   Aberrations  of  general  physique  only — i.e.,  a  pJiy- 
tion  of  structure.  "l  sique  approximating  that  of  the  opposite  sex — 

associated  with  perversion   of   sexual   appetite. 
Most  cases  of  homosexuality  belong  to  this  class. 
[d)   Aberrations  of  general  physique  with  associated 
genital  defects  and  perverted  sexual  appetite. 

In  class  2 — a,  l,  d — are  embraced  epispadias  and  hypospadias  and 
rudimentary  development  or  absence  of  uterus,  ovary,  testicle,  and  penis. 

Much  of  the  rubbish  that  has  been  popularly  accepted  on  the  question 
of  hermaphroditism,  has  been  promulgated  by  men  about  town  and  phy- 
sicians who  are  ignorant  of  sexual  morphology.  On  several  occasions  the 
author  has  been  invited  by  physicians  to  inspect  a  wonderful  hermaphrodite, 
which,  on  examination,  proved  to  be  a  male  of  by  no  means  extraordinarily- 
defective  type.  These  cases  on  investigation  proved  to  be  attaches  of  dis- 
reputable houses  in  which  the  alleged  femininity  of  the  subject  was  being 
devoted  to  profitable  mercantile  designs.  In  one  case — which  was  claimed 
to  be  a  male  pervert — the  subject  afterward  confessed  that  his  perversion 
was  for  revenue  only,  his  sexual  appetite  being  only  gratified  in  the  normal 
manner.  This  was  borne  out  by  the  testimony  of  some  of  his  disreputable 
associates. 


520 


ABEEEAXT    AXD    IMPEEFECT    DIFFEEENTIATION    OF    SEX. 


GiTv/  one  of  tlie  older  writers  on  medical  jurisprudence,  classified  cases 
of  genital  malformation  as  follows: — 

1.  Male .  individuals  with  such 
unusual  formations  of  the  generative 
organs  as  in  many  respects  to  re- 
semble the  female. 

2.  Female  individuals  with  such 
unusual  formations  of  the  same 
organs  as  to  resemble  the  male. 

3.  "Where  a  mixture  of  the  sex- 
ual organs  of  both  sexes  is  exhibited 
without  either  being  entire. 

It  is  obvious  that  there 
are  certain  acquired  condi- 
tions which  would  fall  under 
the  above  classification,  yet 
would  not  be  true  cases  of 
aberrant  sexual  differentia- 
tions: e.g.,  a  prolapsed  and 
hypertrophied  uterus  has  been 
mistaken  for  a  rudimentary 
penis,  and  females  thus  af- 
flicted have  been  known  to 
copulate  with  other  females. 
An  hypertrophied  clitoris  may 
be  mistaken  for  a  rudimentary 
penis  and  may  perform  the 
male  part  in  copulation.  The 
importance  of  caution  in  de- 
ciding the  sex  in  cases  of  gen- 
ital malformation  is  aptly  il- 
lustrated by  a  comparatively 
recent  case  occurring  in  Chi- 
cago. In  this  case  society  was 
electrified  by  the  discovery 
that  a  supposed  young  lady 
who  had  been  visiting  about 
and  sleeping  with  lona  fide 
young  lady  friends  was  a  boy. 
The  first  intimation  of  the 
truth  was  the  development  of  a  pronounced  beard  with  a  bass  vocal  accom- 
paniment. 


Fig.  122. — Aberrant  genitosexual  differentiation 
(hypospadiac).  Male  type,  psychosexually; 
general  physique  of  female  type. 


^  Guy,  op.  cit. 


ABEEEANT   PSYCHOSEXUALITY. 


521 


There  was  considerable  anxiety  for  a  time  lest  tlie  supposed  girl  had 
discovered  his  masculine  qualities  prior  to  their  detection  by  others.  He 
naively  confessed  that  "it  always  did  make  him  feel  funny  to  sleep  with  the 
girls." 

The  assertion  that  certain  cases  of  sexual  perversion  are  akin  to  epi- 
spadias and  hypospadias  and  the  result  of  imperfect  differentiation,  may 
seem  a  trifle  far-fetched,  but  the  author  nevertheless  holds  the  opinion 
that,  even  when  the  differentiation  of  sex  is  complete  from  a  gross  physical 
stand-point  it  is  still  possible  that  the  receptive  and  generative  centers  of 
sexual,  sensibility  may  fail  to  become  perfectly  differentiated.  The  result, 
under  such  circumstances,  might  be,  on  the  one  hand,  sexual  apathy,  and, 


M'l 

>/ 

^ 

'■     /I 

J  ; 

> 

i 

1 

1 

Fig.  123. — Pseudohermaphroditism  (aberrant  genitosexual  differentiation),  show- 
ing vulva,  pseudovagina,  and  absence  of  uterus.     Subject  was  a  male. 

upon  the  other,  an  approximation  to  the  male  or  female  type  according  to 
the  circumstances  of  the  case.  Such  a  failure  of  development  and  imper- 
fect differentiation  of  structu.re  would  necessarily  be  too  occult  for  detection 
from  a  physical  stand-point  by  any  means  of  investigation  at  our  command. 
It  is,  however,  only  too  well  recognized  by  its  results  and  is  often  re- 
sponsible for  disgusting  cases  of  sexual  perversion  that  society  is  prone  to 
attribute  to  moral  depravity.  This  point,  and  the  relation  of  reversion  of 
type  to  sexual  perversion,  will  be  more  fully  discussed  in  the  next  chap- 
ter. That  a  failure  of  differentiation  and  development  is  equally  responsible 
for  certain  cases  of  sexual  perversion  and  instances  of  hypospadias  and  epi- 
spadias is  the  principal  point  to  be  remembered  at  this  juncture. 


522  ABEEEAXT    AXD    IISIPEEFECT    DirFEEEXTIATIOX    OF    SEX. 

Cases  of  gross  physical  aberration  of  genital  structure  are  not  difficult 
to  account  for,  so  far  as  the  modus  opera.ndi  of  their  formation  is  concerned; 
but  their  cause  is  not  so  readily  explicable.  How  far  maternal  impressions 
enter  into  the  causation  of  genital  deformity  is  a  question  upon  which  it  is 
to  be  hoped  much  light  may  some  day  be  shed. 

There  is  eyidently  an  exhaustion  of  formatiye  energy  before  the  oc- 
currence of  complete  fusion  of  the  two  lateral  segments,  of  which  the  em- 
bryo is  practicalh'  composed.  Defective  genital  formation  bears  the  same 
relation  to  this  exhaustion  of  formative  energy  as  do  crania  lifida,  spina 
bifida,  etc.  It  is  obvious  that  the  degree  of  deformity  depends  entirely 
upon  the  period  at  which  developmental  progression  ceases.  So  far  as  ap- 
pearances go,  one  would  naturally  conclude  that  differentiation  does  not 
cease  at  a  very  early  period  in  the  life-history  of  the  fetus,  else  what  is  ordi- 
narily accepted  as  true  hermaphroditism  would  not  only  occur  in  reality, 
but  would  be  frequent. 

G-eoffroy  St.  Hiliare,  one  of  the  older  writers,  mapped  out  a  very  elabo- 
rate plan  in  explanation  of  hermaphroditism  in  a  work  especially  devoted 
to  that  subject.  He  divided  the  generative  apparatus  into  a  series  of  por- 
tions or  segments,  three  in  each  lateral  division.  The  upper  set  comprised 
the  testes  and  ovaries;  the  middle  the  womb,  prostate,  and  seminal  vesi- 
cles; the  lower  the  penis,  scrotum,  clitoris,  and  vulva.  According  to  him, 
therefore,  there  might  occur  any  number  of  varieties  of  hermaphroditism, 
according  to  the  combination  of  faulty  structures.  This  scheme  was  de- 
fective because  of  the  fact  that,  in  spite  of  all  appearances  to  the  contrary, 
differentiation  never  falls  quite  short  of  determining  one  or  the  other  sex. 

The  simplest  plan  for  the  explanation  of  genital  deformities  and  anom- 
alies is  to  remember  that  the  fetus  practically  develops  in  two  lateral  seg- 
ments and  that  any  failure  of  union  at  the  genital  furrow  will  result  in  a 
greater  or  less  degree  of  aberration  of  genital  conformation.  The  view  that 
hypospadia  and  epispadia  are  the  result  of  atresia  and  rupture  of  the  fetal 
urethra^  is  apparently  untenable  in  view  of  the  generally-defective  physique 
found  in  most  cases  of  the  kind. 

The  relation  of  aberrations  of  genital  formation  to  sterility  and  im- 
potence is  very  important.  Impotence  does  not  exist  in  the  female  unless 
there  be  atresia  or  complete  absence  of  the  vagina.  Almost  any  aberration 
of  the  structure  of  the  ovary  or  uterus  ma}',  however,  produce  sterility.  In 
the  male  impotency  is  more  apt  to  result  than  sterility,  as  serious  deformity 
may  prevent  either  erection  or  sufficient  development  of  the  organ  to  per- 
mit intromission.  Xo  matter  how  great  the  deformity,  however,  the  in- 
dividual may  be  fruitful  if  circumstances  be  favorable,  so  long  as  the  tes- 
ticles are  functionally  perfect. 


^  Thiersch  and  Tilden  Brown :     "ISIorrow'.?  System  of  Genito-Urinaiy  and  Skin 
Diseases." 


DIAGNOSIS    OF    SEX.  523 

In  determining  the  sex  of  alleged  hermaphrodites  the  following  points 
require  consideration: — 

1.  The  character  of  the  voice. 

2.  The  development  of  the  mammse. 

3.  The  growth  or  absence  of  beard. 

4.  The  form  of  the  shoulders,  hips,  and  waist. 

5.  The  presence  or  otherwise  of  the  menses  or  vicarious  discharges. 

6.  The  character  of  sexual  desire.  In  respect  to  this  point  the  occa- 
sional co-existence  of  sexual  perversion  with  genital  deformity  should  be 
given  its  due  meed  of  consideration.  Thus,  in  a  case  in  which  difficulty  of 
diagnosis  existed  a  perverted  sexual  affinity  for  the  same  sex  might  mislead 
the  physician. 

7.  The  presence  or  absence  of  rudimentary  (or  perfect)  testes  or  ovaries. 

8.  The  form  of  the  supposed  clitoris  or  penis,  the  method  of  attach- 
ment of  its  prepuce,  and  the  absence  or  presence  of  perforation  in  its  glans. 

9.  The  presence  or  absence  of  the  hymen  (rudimentary),  nymphse, 
labia  majora,  or  bifid  scrotum,  as  the  case  may  be.  In  cases  of  doubt  it  is 
safest  to  regard  the  individual  as  a  female  until  time  and  pubescence  have 
settled  the  question. 

The  cases  of  imperfect  or  aberrant  sexual  diff'erentiation  included  un- 
der the  head  of  sexual  perversion  are  obviously  more  difficult  to  study  than 
those  in  which  the  aberration  is  of  a  purely  physical  character.  This  is 
especially  true  regarding  sapphic  love,  or  sexual  af&nity  of  female  for 
female.  That  such  cases  are  frequent  is  certain,  but  they  are  extremely  dif- 
ficult to  trace.  The  confessional  of  the  family  physician  doubtless  might 
offer  evidence  of  a  clinical  character,  but  he  is  very  chary  of  airing  the  short- 
comings of  his  patients  in  this  particular  direction. 

The  existence  of  this  aberrant  sexuality  can  only  be  explained  by  aber- 
rant psychosexual  differentiation.  In  the  ease  of  the  male,  instances  are 
so  common  that  the  subject  is  decidedly  trite.  It  is  not  only  charity,  but 
a  sense  of  justice  and  a  desire  to  lessen  the  stigma  upon  human  nature,  that 
impels  the  author  to  include  typic  cases  of  sexual  perversion  under  the 
head  of  aberrant  sexual  differentiation,  and  to  attribute  the  condition  to 
perverted  or  imperfect  evolutionary  development,  on  the  one  hand,  and  a 
reversal  of  t3^pe,  on  the  other. 


CHAPTEE  XXII. 

Diseases  of  the  Sexual  Function  and  Instinct. 

Geneeal  Considerations. — The  sexual  function  is  animated  by  the 
most  vital  of  all  animal  instincts.  When  made  to  subserve  its  real  purpose 
— procreation — sexual  desire  is  fundamentally  the  most  disinterested  of  the 
purely  animal  appetites.  G-ranting  that  it  is  a  mere  difEerentiation  of  its 
ancestral  instinct^  hunger,  its  ultimate  object  is  higher  than  that  of  the 
parent  appetite.  The  ultimate  object  of  hunger  is  the  preservation  of  the 
life  of  the  individual,  while  that  of  the  sexual  passion  is  the  preservation 
of  the  species.  The  fact  that  the  individual  derives  pleasure  from  the  sex- 
ual act  detracts  not  at  all  from  the  unselfishness  of  its  object,  so  far  as  its 
relation  to  the  grand  scheme  of  jSTature  is  concerned.  The  sexual  passion 
is  no  more  open  to  impeachment  on  the  ground  of  selfishness  than  is  the 
fundamental  instinct  of  hunger.  Both  are  alike  productive  of  pleasure  in 
their  gratification;  both  are  alike  subject  to  abuse  by  those  who  pursue 
the  pleasure  of  gratification  of  the  animal  appetites  with  a  total  disregard 
of  their  natural  objects.  There  are  relatively  few  who  "eat  to  live'^;  those 
who  live  to  eat  are  legion.  The  proportion  of  human  beings  who  copulate 
for  procreative  purposes  is  very  small  as  compared  with  those  for  whom 
the  sexual  act  is  the  axis  upon  which  the  world  revolves. 

As  regards  his  sexual  ethics,  man  has  probably  retrograded  from  the 
primal  stock  from  which  he  has  descended — or  ascended,  according  to  the 
point  of  view.  Those  of  the  lower  animals  that  modern  human  society  pre- 
tends to  imitate — the  monogamous  types — are  vastly  superior  to  man  from 
the  sexual  stand-point.  The  pairing  of  animals,  even  though  it  be  for  a 
limited  period  only,  means  something.  The  unwritten  law  is  unbroken. 
With  human  beings,  the  contract  involved  in  the  pairing  system  legiti- 
matized in  monogamous  social  organizations,  means  much  or  little,  accord- 
ing to  the  moral  bent  and  sexual  capacity  of  the  individual. 

The  sexual  immorality  and  perverted  sexual  physiology  of  the  human 
race  is  generally  discussed  from  the  stand-point  of  morals,  with  a  total  dis- 
regard for  common  sense,  to  say  nothing  of  natural  law.  It  does  not  seem 
to  occur  to  the  moralist  and  would-be  social  reformer  that  there  is  an  or- 
ganic basis  for  sexual  infractions  of  moral  and  physiologic  law — still  less  is 
it  understood  that  the  moral  code  is  a  relative  matter,  devised  to  subserve 
some  selfish  motive  or  other,  with  a  total  disregard  for  natural  law. 

The  question  of  the  relative  social  value  and  safety  of  monogamy  and 
polygamy  is  too  broad  for  discussion  here.  That  monogamy,  from  a  socio- 
logic  stand-point,  irrespective  of  arbitrary  moral  codes,  is  best  adapted  to 
our  own  social  necessities,  is  admitted.  That  it  is  in  conformity  with  nat- 
ural law  so  far  as  the  human  race  is  concerned,  the  author  does  not  believe. 

(524) 


GENERAL    CONSIDEEATIONS.  525 

Man,  by  nature,  instinct,  and  physiologic  demand,  is  a  polygamous  animal. 
Monogamy,  like  many  other  social  customs,  is  a  sacrifice  of  natural  law  to 
personal  and  social  selfishness  and  expediency.  The  sexual  immorality  and 
perverted  sexual  physiology  of  man — taking  our  own  moral  code  as  the 
standard — are  the  result  of  the  battle  of  social  with  natural  man. 

If  man  is  basically  a  monogamous  animal,  nature  builds  poorly  and  is 
an  unreliable  physiologic  conservator.  It  is  evident  that,  inasmuch  as  the 
object  of  the  sexual  function  is  the  preservation  of  the  species,  the  act  of 
copulation  should  be  performed  only  at  such  times  and  under  such  circum- 
stances as  subserve  that  object.  In  the  lower  monogamous  animals  copula- 
tion and  desire  both  cease  with  impregnation.  This  does  not  hold  good 
with  the  human  species.  Even  with  polygamous  animals  the  beginning  of 
breeding  heralds  the  cessation  of  copulation.  The  domestic  fowl — ^whose 
polygamy,  by  the  wa}',  was  originally  acquired  through  forced  adaptation 
to  the  commercial  demands  of  its  human  proprietors — presents  a  shining 
example  of  the  relative  decency  of  polygamy  so  far  as  the  female  is  con- 
cerned. 

To  even  hint  that  the  female  of  the  human  species  was  originally 
designed  for  a  monogamous  animal  is  perhaps  dangerous,  after  expressing 
the  opinion  that  the  male  is  polygamous  by  nature,  yet  the  author  unhesi- 
tatingly affirms  that  view.  A  certain  proportion  of  females  experience  sex- 
ual desire  even  during  gestation,  but  the  fact  remains  that  desire  is  rela- 
tively feeble  in  women,  as  a  rule,  and  normally  coitus  should  be  repugnant 
to  the  female  during  gestation.  Where  it  is  not,  there  is  simply  hereditarily- 
perverted  sexual  physiology  due  to  the  unphysiologic  approaches  of  the  male 
practiced  from  time  immemorial,  or  local  irritation  from  disease.  Socially 
it  is  not  well  that  there  should  be  "one  law  for  the  man  and  another  for 
the  woman,"  but  such,  apparently,  was  Nature's  original  intention,  however 
much  it  has  been  subverted  to  social  demands  and  individual  selfishness. 

While  in  no  sense  desiring  to  apologize  for  the  sexual  immorality  and 
perverted  sexual  physiology  of  the  human  race,  the  author  firmly  believes 
that  much  of  it  is  explicable  upon  the  foregoing  grounds.  This  view  is 
especially  pertinent  with  respect  to  the  etiology  of  sexual  excess.  Man  and 
woman  alike  have  suffered  from  abrogation  of  natural  law.  It  is,  of  course, 
admitted  that  polygamy  as  practiced  in  the  harems  of  the  Orient  is  like- 
wise productive  of  perverted  sexual  physiology;  but  the  basic  sexual  in- 
stinct of  the  human  male  is  in  nowise  responsible  for  his  abuse  of  the  sex- 
ual function. 

Ignorance  of  sexual  physiology  is  one  of  the  fundamental  causes  of 
diseases  of  the  sexual  function,  and  especially  of  those  produced  by  mas- 
turbation. Society  imposes  certain  sexual  restrictions  upon  the  human  race, 
while  at  the  same  time  discountenancing  the  acquirement  of  knowledge  of 
the  sexual  function  and  its  object.  Society  also  furnishes  the  worst  pos- 
sible environment  for  its  own  moral  ends.     The  natural  desires,  especially 


526  DISEASES    OF    THE    SEXUAL    FUXCTIOX   AXD    IXSTIX'CT. 

of  the  male,  are  excited  by  yarions  impressions  to  wMch  lie  is  exposed  until 
sexnal  irritability  inevitably  results.  The  indiyidual  is  then  asked  to  be 
chaste  and  virtuous,  notwithstanding  the  fact  that  society  furnishes  him 
with  an  environment  that  would  lead  one  to  infer  that  virtue  is  an  unknown 
quantity.  Society  has  not  changed  its  moral  law — written  or  unwritten — 
pari  passu  with  its  advancing  wickedness.  It  is  not  so  many  years  since 
such  books,  pictures,  and  plays  as  are  tolerated  to-day  were  tabooed.  Latter- 
day  art,  literature,  and  stage  furnish  an  atmosphere  of  sexual  immorality  to 
which,  sooner  or  later,  every  youth — male  or  female — is  inevitably  exposed. 
Tabooed  books  and  pictures  are  not  very  dangerous;  the  person  who  in- 
dulges in  them  knows  full  well  that  such  things  are  evil.  Trilby,  the  fad, 
did  more  damage  to  the  sexual  morale  of  society  than  all  the  tabooed  ob- 
scene books  ever  written.  Clandestine  vice,  known  to  be  under  the  ban,  is 
honest  enough,  to  say  the  least.  Yiee  thinly  veiled,  or  gilded  over  by  the 
mawkish  sentiment  engendered  by  Trilby  pink  teas  and  yellow  breakfasts 
and  apologized  for  by  social  faddists,  is  insidious  and  deadly.  A  Magdalen 
repentant  has  ever  been  a  lesson  in  morality,  but  the  naive  admission  of 
Trilby  that  she  had  had  a  certain  limited  number  of  lovers  can  hardly  be 
admitted  to  Magdalenic  literature. 

The  example  often  set  by  stage  people  in  their  private  (sic)  lives,  toler- 
ated as  it  is  by  society,  is  a  very  dangerous  factor  in  the  promulgation  of 
sexual  immorality.  Society  proclaims  from  the  house-tops:  "Thou  shalt 
not^^;  and  then  whispers  softly  in  the  ear  of  the  favored  ones:  "Of  course, 
I  don't  mean  geniuses  like  you."  And  the  favored  and  talented  few  go  on 
and  on,  even  exploiting  their  sexual  derelictions  for  advertising  purposes. 

The  public  press  must  come  in  for  its  share  of  blame  in  the  promulga- 
tion of  pernicious  sexual  impulses  among  the  young.  Sexual  immorality 
is  either  condoned  or  discussed  in  a  tone  of  flippancy  that  amounts  to  con- 
donation. To  the  minds  of  the  young  and  inexperienced,  sexual  license 
would  seem  to  be  the  unwritten  code  of  modern  society. 

Is  it  fair  that  society  should  demand  that  the  young  should  remain  in 
ignorance  of  the  physiologic  side  of  sexual  matters,  while  its  vicious  aspects 
are  paraded  in  all  their  nakedness?  How  difficult  the  task  of  the  mother 
who  endeavors  to  inculcate  purity  in  the  minds  of  her  daughters!  And  how 
much  more  difficult  the  task  of  the  father  who  endeavors  to  keep  his  son 
off  the  rocks  and  shoals,  not  by  teaching — often  not  by  example — but  by 
discipline! 

The  sum-total  of  results  is  that  the  growing  lad  comes  to  regard  sexual 
purity  as  something  to  be  ashamed  of,  and  female  virtue  as  extremely  out 
of  fashion.  Young  girls,  too,  are  likely  to  regard  with  tolerant  eyes  those 
moral  lapses  which  are  common  to  social,  literary,  and  stage  lions.  The 
resultant  evils  are  sufficiently  obvious. 

Inasmuch  as  society  has  practically  thrown  down  all  but  the  traditional 
theoretic  barriers  between  sexual  purity  and  impurity,  it  would  seem  that 


GENEEAL    COXSIDEEATIOXS.  527 

abuses  of  sexual  physiology  can  only  be  combated  upon  purely  physical 
grounds.  In  a  certain  sense,  too,  the  selfishness  of  the  individual  must  be 
appealed  to.  Young  lads  should  be  taught  that  masturbation  is  dangerous 
to  their  physical  well-being — that  they  can  never  become  as  perfect  men, 
morally,  physically,  or  intellectually,  if  they  indulge  prematurely  in  any 
sort  of  exercise  of  the  sexual  function  as  they  will  if  they  remain  continent. 
The  young  lad's  instinct  of  self-preservation  will  accomplish  much  more 
than  lessons  in  morality  that  are  momentarily  being  contradicted  by  scenes, 
persons,  and  incidents  about  him.  A  most  profound  impression  may  often 
be  made  by  stating  that  early  indulgence  blunts  sexual  sensibility,  and  thus 
to  a  certain  degree  deprives  the  individual  of  the  legitimate  pleasures  of 
his  later  matrimonial  life.  And  this  statement  is  by  no  means  exaggerated. 
It  is  probable  that  no  man  who  has  indulged  in  sexual  congress  or  masturba- 
tion to  any  degree  prior  to  full  maturity  is  ever  possessed  of  normal  sexual 
sensibility  in  later  life. 

The  psychic  effect  of  early  sexual  indulgence  and  masturbation  is  even 
more  deleterious  than  the  purely  physical.  Youth  is  imaginative,  as  well 
as  hyperesthetic,  and  its  pleasures  are  consequently  relatively  keen.  The 
sexual  experiences  of  youth  so  mold  the  psychosexual  centers  that  a  stand- 
ard is  set  for  all  future  sexual  experiences.  The  adult  life  of  the  individual 
is  often  devoted  to  the  pursuit  of  a  sexual  ideal  that  exists  only  in  his  brain 
— an  ideal  that  is  but  a  memory  of  his  younger  and  more  impressionable 
days.  This  ideal  is  the  will-o'-the-wisp  that  leads  many  men  into  sexual 
immorality  and  excess. 

Wise  counsel  and  intelligent  instruction  of  young  lads  in  sexual  matters 
might  do  more  for  the  morals  of  society  than  any  amount  of  preaching. 

Much  has  been  said  of  the  evils  of  quack  literature  in  polluting  the 
minds  of  the  young,  still  more  has  been  said  of  the  harpy-like  proclivities 
of  the  quack.  There  is,  however,  something  to  be  said  upon  the  other 
side  of  the  question.  There  is  a  "soul  of  good  in  things  evil."  Many  lads 
would  go  on  in  their  evil  ways  indefinitely  did  they  not  stumble  upon  quack 
literature,  which,  while  exaggerating  the  evils  of  masturbation  and  sexual 
excess,  none  the  less  sounds  the  first  note  of  warning  they  have  ever  re- 
ceived. The  profession  is  largely  responsible  for  this,  by  crying  down  any 
attempt  on  the  part  of  scientific  men  to  impart  knowledge  of  sexual  matters 
to  the  laity.  Why  the  profession  should  join  the  ignorant  public  in  tabooing 
sexual  knowledge  is  a  mystery,  quite  as  much  so  as  a  great  deal  of  other 
cant  and  hypocrisy  that  has  pervaded  the  medical  profession  from  time  im- 
memorial. So-called  ethics  has  done  more  to  foster  quackery  than  to  pre- 
vent it.  And  the  public  smiles  derisively  at  a  profession  which,  after  years 
of  travail,  will  tolerate  "practice  limited  to  diseases  of  women"  on  profes- 
sional cards;  yet  would  roll  up  its  eyes  like  a  dying  rabbit  should  it  per- 
chance run  across  a  card  inscribed:  "diseases  of  men  only."  Precisely  what 
phase  of  sentiment  elevates  a  woman  with  a  leucorrhea  to  a  higher  plane 


538  DISEASES    OE    THE    SEXUAL    FUXCTIOX   AXD   IXSTIXCT. 

than  that  which  a  man  with  spermatorrhea  occupies  is  one  of  the  things 
which,  as  Dundreary  says,  "no  fellow  can  find  out."  Irrespective  of  cause, 
it  is  a  deplorable  fact  that  the  regular  profession  is  woefully  ignorant  and 
culpably  negligent  regarding  the  sexual  ailments  of  its  clientele. 

The  respectable  physician  is  still  laughing  at  the  complaints  of  men 
who  consider  themselves  impotent,  on  the  one  hand,  and  prescribing  vir- 
gins for  broken-down  roues  and  sexual  wrecks,  on  the  other.  The  fact  that 
the  virgins  are  to  be  sacrificed  on  Hymen's  altar  satisfies  the  medical  im- 
becile who,  like  the  ostrich,  has  his  head  in  the  sand,  and  the  sacrifice  at 
the  same  time  conforms  with  social  demand.  The  impotent  man  should 
receive  intelligent  advice  from  the  general  practitioner.  The  man  who  is 
unable  to  copulate  is  face  to  face  with  a  grim  reality.  Whether  psychic  or 
not,  his  impotence  is  a  material  fact  of  which  he  is  only  too  keenly  con- 
scious. As  for  the  virgins  who  are  daily  prescribed  as  placebos  or  panaceas, 
it  is  high  time  they  were  represented  at  court.  The  remedy  lies  with  the 
profession.  The  sexual  organs  and  function  are  the  noblest  attributes  of 
man,  and  their  diseases  are  quite  as  worthy  of  intelligent  study  and  con- 
siderate treatment  as  affections  of  other  organs.  False  modesty  and  mawk- 
ish sentiment  have  no  place  in  scientific  medicine.  At  present,  the  igno- 
rance and  mock  prudery  of  a  large  proportion  of  the  profession  is  absolutely 
sickening. 


CHAPTER  XXIII. 

ABERRATIONS  OF  THE  SEXUAL  INSTINCT. 

Sexual  Perveesion  and  Ixveesion. 

The  subject  of  sexual  perversion, — Contrare  Sexualempfindung, — al- 
though a  disagreeable  one  for  discussion,  demands  the  attention  of  the 
scientific  physician,  and  is  of  great  importance  in  its  social,  medical,  and 
legal  relations.  J.  G-.  Kiernan,  in  discussing  the  hypothetic  dependence  of 
the  Whitechapel  murders  upon  sexual  perversion,  says: — 

The  subject  may  seem  to  trench  on  the  "prurient,"  which  in  medicine  does  not 
exist,  since  "science,  like  fire,  purifies  everything,"  and  what  Macalilay  caUs  "the 
mightiest  of  human  instincts"  is  too  intimately  related  to  the  physical  basis  of  human 
weal  and  woe  for  any  physician  prudishly  to  ignore  any  of  its  phases.^ 

The  subject  has  been  until  a  recent  date  studied  solely  from  the  stand- 
point of  the  moralist,  and,  from  the  indisposition  of  the  scientific  physician 
to  study  them,  the  unfortunate  class  of  individuals  who  are  characterized 
by  perverted  sexuality  have  been  viewed  in  the  light  of  their  moral  respon- 
sibility rather  than  as  victims  of  a  physical,  and  incidentally  of  a  mental, 
defect.  It  is  certainly  much  less  humiliating  to  us  as  atoms  of  the  social 
fabric  to  be  able  to  attribute  the  degradation  of  these  poor  unfortunates  to 
a  physical  cause  than  to  a  willful  viciousness  over  which  they  have,  or  ought 
to  have,  volitional  control.  Even  to  the  moralist  there  should  be  much  sat- 
isfaction in  the  thought  that  a  large  class  of  sexual  perverts  are  physically 
abnormal  rather  than  morally  leprous.  It  is  often  difficult  to  draw  the  line 
of  demarkation  between  physical  and  moral  perversion.  Indeed,  the  one  is 
so  often  dependent  upon  the  other  that  it  is  doubtful  whether  it  were  wise 
to  attempt  the  distinction  in  many  instances.  But  this  does  not  affect  the 
cogency  of  the  argument  that  the  sexual  pervert  is  generally  a  physical 
aberration — a  lusus  naturce. 

Krafft-Ebing^  expresses  himself  upon  this  point  as  follows: — 

In  former  years  I  considered  contrare  Sexualempfindung  as  a  result  of  neuro- 
psychic  degeneration,  and  I  believe  that  this  view  is  warranted  by  more  recent  investi- 
gations. As  we  study  into  the  abnormal  and  diseased  conditions  from  which  this 
malady  results,  the  ideas  of  horror  and  criminality  connected  with  it  disappear,  and 
there  arises  in  our  minds  the  sense  of  duty  to  investigate  what  at  first  sight  seems 
so  repulsive,  and  to  distinguish,  if  may  be,  between  a  perversion  of  natural  instincts 


^Medical  Standard,  November,  1888. 

-  Journal  of  Psychiatry  and  Neurology,  vol.  ix,  No.  4,  p.  565. 

^*  (529) 


530  SEXUAL    PEJRYERSIOX   AXD    IXYEESIOX. 

which  is  the  result  of  disease  and  the  criminal  offences  of  a  pei-verted  mind  against 
the  laws  of  morality  and  social  decency.  By  so  doing  the  investigations  of  science 
will  become  the  means  of  rescuing  the  honor  and  re-establishing  the  social  position 
(sic)  of  many  an  unfortunate  whom  unthinking  prejudice  and  ignorance  would  class 
among  depraved  criminals.  It  would  not  be  the  first  time  that  science  has  rendered 
a  service  to  justice  and  to  society  by  teaching  that  what  seem  to  be  immoral  con- 
ditions and  actions  are  but  the  results  of  disease. 

There  is  in  every  community  of  any  size  a  colony  of  male  sexual  per- 
verts; tlie}^  are  usually  known  to  each  other,  and  are  likely  to  congregate 
together.  At  times  they  operate  in  accordance  with  some  definite  and  con- 
certed plan  in  quest  of  suhjects  wherewith  to  gratify  their  abnormal  sexual 
impulses.  Often  they  are  characterized  by  effeminacy  of  voice,  dress,  and 
manner.  In  a  general  way,  their  physique  is  apt  to  be  inferior — a  defective 
physical  make-up  being  quite  general  among  them,  although  exceptions  to 
this  rule  are  numerous. 

Sexual  perversion  is  more  frequent  in  the  male;  women  usually  fall 
into  perverted  sexual  habits  for  the  purpose  of  pandering  to  the  depraved 
tastes  of  their  patrons  rather  than  from  instinctive  impulse.  Exceptions 
to  this  rule  are  occasionally  seen.  For  example,  the  instance  of  a  woman  of 
perfect  physique,  who  is  not  a  professional  prostitute,  but  moves  in  good 
societ}',  who  has  a  fondness  for  women,  being  never  attracted  to  men  for 
the  purpose  of  ordinary  sexual  indulgence,  but  for  perverted  methods.  The 
physician  rarely  has  his  attention  called  to  these  things,  and,  when  evidence 
of  their  existence  is  placed  before  him,  he  is  apt  to  receive  it  with  skep- 
ticism. He  regards  tlie  subject  as  something  verging  on  Mlinchausenism, 
or,  if  the  matter  seem  at  all  credible,  he  sets  it  aside  as  something  unholy 
with  which  he  is  not  or  should  not  be  concerned.  It  is,  indeed,  not  to  be 
wondered  at  that  the  physician,  who  sees  so  much  to  disgust  him  with  the 
human  animal,  should  be  reluctant  to  add  to  his  store  of  contempt.  The 
nian  about  town  is  very  often  au  fait  in  these  matters  and  can  give  very 
valuable  information.  Indeed,  witnesses  enough  can  be  found  to  convince 
the  most  skeptic. 

Sexual  perversion  ma}'  be  best  defined,  in  a  general  way,  as  the  pos- 
session of  impulses  to  sexual  gratification  in  an  abnormal  manner,  with  a 
partial  or  complete  apathy  toward  the  normal  method. 

The  affection  presents  itself  in  several  forms,  which  may  be  tabulated 
as  follows: — 

(a)  Sexual  perversion  without  defect  of  struct- 

ure  of  sexual  organs. 

°  ]   (b)  Sexual   perversion   with    defect    of   genital 

haps  hereditary  sex-  (  ,       ,  ,  -u     j-^- 

^  .     -^  ^  structure:   e.g.,  hermaphroditism. 

•P  ■  /(f)  Sexual   perversion   with   obvious   defect   of 

cerebral  development:   e.g.,  idiocy. 


VARIETIES    OF    SEXUAL    PERVEESIOX.  531 

(a)  Sexual  perversion  from  pregnancy,  the 
menopause,  ovarian  disease,  hysteria,  etc. 

(b)  Sexual  perversion  from  acquired  cerebral 
disease,   with   or  without  recognized  in- 

II.  Acquired  sexual  per-    j  sanity. 

version.  '^    (c)  Sexual  perversion  (?)  from  vice. 

(d)  Sexual  perversion  from  overstimulation  of 
the  nerves  of  sexual  sensibility  and  the 
receptive  sexual  centers  incidental  to  sex- 
ual excesses  and  masturbation. 

When  the  author's  classification  as  above  presented  first  appeared,  it 
was  by  no  means  cordially  received,  its  practicality  being  overlooked.  Its 
recent  adoption  by  Havelock  Ellis,  who  asserts  its  superiority  to  Krafft- 
Ebing's  classification,  is  extremely  gratifying.^ 

As  regards  the  clinical  manifestations  of  the  disease,  sexual  perverts 
may  be  classified  as:  (a)  those  having  a  predilection  (affinity)  for  their  own 
sex;  (6)  those  having  a  predilection  for  abnormal  methods  of  gratification 
with  the  opposite  sex;  (c)  those  affected  with  bestiality.  Instances  of  all 
these  different  varieties  have  been  observed. 

It  is  hardly  necessary  to  say  that  the  sexual  pervert  is  by  no  means  a 
modern  institution.  Sexually-perverted  conduct  evidently  characterized 
some  of  the  ancient  orgies.  It  is  certain  that  sexual  perversion  was  prev- 
alent in  the  time  of  Nero.  The  author  is  not  aware  that  attention  has 
hitherto  been  called  to  the  Scriptural  evidence  of  its  ancient  existence.  If, 
however,  Scriptural  chronology  be  correct,  it  was  recognized  at  least  as 
early  as  a.d.  60.  Positive  proof  of  this  is  seen  in  the  Epistle  of  Paul  to 
the  Eomans:   Chapter  I;  24,  26,  27,  and  28  verses.    The  text  reads: —    / 

Wherefore  God  also  gave  them  up  to  uncleanness  through  the  lusts  of  their  own 
hearts,  to  dishonor  their  own  bodies  between  themselves. 

Who  changed  the  truth  of  God  into  a  lie,  and  worshipped  and  served  the  creature 
more  than  the  Creator,  who  is  blessed  forever.    Amen. 

For  this  cause  God  gave  them  up  unto  vile  affections;  for  even  their  women 
did  change  the  natural  use  into  that  which  is  against  nature;  and  likewise  also  the 
men  leaving  the  natural  use  of  the  women,  burned  in  their  lust  one  toward  another; 
men  with  men  working  that  which  is  unseemly,  and  receiving  in  themselves  that 
recompense  of  their  error  which  Avas  meet. 

And  even  as  they  did  not  like  to  retain  God  in  their  knowledge,  God  gave 
them  over  to  a  reprobate  mind,  to  do  those  things  which  are  not  convenient. 

The  Scriptural  authority  thus  quoted  may  not  add  any  particular  dig- 
nity to  the  subject  of  sexual  perversion,  but  it  is  certainly  of  interest  as 
showing  the  early  recognition  of  this  peculiar  morbid  state. 


2  Havelock  Ellis,  "Psychology  of  Sex. 


532  SEXUAL    PEETEESIOX   AXD   IXVEESIOX. 

The  precise  causes  of  sexual  perversion  are  obscure.  The  explanation 
of  the  phenomenon  is,  in  a  general  way,  much  more  definite.  Just  as  we 
may  have  variations  of  phj^sical  form  and  of  mental  attributes  in  general, 
so  we  may  have  variations  and  perversions  of  that  intangible  entity:  sexual 
affinity.  In  some  cases,  perhaps,  sexual  differentiation  has  been  psychically 
imperfect,  and  there  is  a  reversion  of  type;   as  Kiernan  remarks: — 

The  original  bisexuality  of  the  ancestors  of  the  race,  shown  in  the  rudimentary 
female  organs  of  the  male,  could  not  fail  to  occasion  functional,  if  not  organic,  rever- 
sions ^Yhen  mental  or  physical  manifestations  were  interfered  with  by  disease  or  con- 
genital defect.  The  inhibitions  on  excessive  action  to  accomplish  a  given  purpose, 
which  the  race  has  acquired  through  centuries  of  evolution,  being  removed,  the  animal 
in  man  springs  to  the  surface.  Removal  of  these  inhibitions  produces,  among  other 
results,  sexual  perversion. 

Eeasoning  back  to  cell-life,  we  see  many  variations  in  sexual  af&nity 
and  the  function  of  reproduction  between  the  primal  segmentation  of  the 
cell — the  lowest  tj'pe  of  procreative  action — and  that  complete  and  perfect 
differentiation  of  the  sexes  which  requires  a  definite  act  of  sexual  congress 
as  a  manifestation  of  the  acme  of  sexual  affinity,  and  for  the  purpose  of 
reproduction.  The  variations  in  the  methods  of  sexual  gratification — or, 
to  attribute  it  to  instinct,  of  perpetuating  the  species — which  are  presented 
to  the  student  of  natural  history  are  numerous  and  striking.  It  is  not  the 
author's  intention,  however,  to  give  this  matter  more  than  passing  notice. 
The  method  of  sexual  gratification — i.e.,  procreation — of  fishes  is  a  curious 
phenomenon.  It  is  difficult  to  appreciate  the  sexual  gratification  involved 
in  the  deposition  of  the  milt  of  the  male  fish  upon  the  spawn  of  the  female, 
yet  that  the  so-called  instinctive  act  of  the  male  is  unattended  by  gratifica- 
tion is  improbable.  Indeed,  it  is  an  argument  as  applicable  to  the  lower 
animals  as  to  man,  that,  were  the  act  of  procreation  divested  of  its  pleas- 
urable features,  the  species  would  speedily  become  extinct:  for  the  act  of 
procreation  pe?'  se  is  possessed  of  no  features  of  attractiveness,  but  of  many 
that,  are  repulsive,  and  in  themselves  productive  of  discomfort. 

It  is  puzzling  to  the  healthy  man  and  woman  to  understand  how  the 
practices  of  the  sexual  pervert  can  afford  gratification.  If  considered  in  the 
light  of  reversion  of  type,  however,  the  subject  is  much  less  perplexing. 
That  maklevelopment,  or  arrested  development,  of  the  sexual  organs  should 
be  associated  with  sexual  perversion  is  not  at  all  surprising;  and  the  more 
nearly  the  individual  ai^proximates  the  type  of  fetal  development  which 
exists  prior  to  the  commencement  of  sexual  differentiation,  the  more  marked 
is  the  aberrance  of  sexuality,  of  which  more  anon. 

There  is  one  element  in  the  study  of  sexual  perversion  that  deserves 
especial  attention.  It  is  probable  that  few  bodily  attributes  are  more  readily 
transmitted  to  posterity  than  peculiarities  of  sexual  ph3'-siology.  The  off- 
spring of  the  abnormally-carnal  individual  is  likely  to  be  possessed  of  the 
same  inordinate  sexual  appetite  that  characterizes  the  parent.    The  child  of 


ETIOLOGY    OF    SEXUAL    PERVEESIOX    AXD    INVEESIOX.  533 

vice  has  within  it,  in  many  instances,  the  germ  of  vicious  impulse,  and  no 
purifying  influence  can  save  it  from  following  its  own  inherent  inclinations. 
Men  and  women  who  seek,  from  mere  satiety,  variations  of  the  normal 
method  of  sexual  gratification,  stamp  their  nervous  systems  with  a  malign 
influence  which  in  the  next  generation  may  present  itself  as  true  sexual 
perversion.  Acquired  sexual  perversion  in  one  generation  maji'  be  a  true 
constitutional  and  irradicable  vice  in  the  next,  and  this  independently  of 
grosa  physical  aberrations.  Carelessness  on  the  part  of  parents  is  responsible 
for  some  cases  of  acquired  sexual  perversion.  Boys  who  are  allowed  to  as- 
sociate intimately  are  apt  to  turn  their  inventive  genius  to  account  by  in- 
venting novel  means  of  sexual  stimulation,  with  the  result  of  ever  after 
diminishing  the  natural  sexual  appetite.  Any  powerful  impression  made 
upon  the  sexual  system  at  or  near  puberty,  when  the  sexual  apparatus  is 
just  maturing  and  very  active,  although  as  yet  weak  and  impressionable,  is 
apt  to  leave  an  imprint  in  the  form  of  sexual  peculiarities  that  will  haunt 
the  patient  throughout  his  after-life.  Sexual  congress  at  an  early  period 
often  leaves  its  impression  in  a  similar  manner.  Many  an  individual  has 
.  had  reason  to  regret  the  indulgences  of  his  youth  because  of  its  moral  effect 
upon  his  after-life.  The  impression  made  upon  him  in  the  height  of  his 
youthful  sensibility  is  never  eradicated,  but  remains  in  his  memory  as  his 
ideal  of  sexual  matters,  for  there  is  a  physical  as  well  as  a  psychic  memory. 
As  he  grows  older  and  less  impressionable,  he  seeks  vainly  for  an  experience 
similar  to  that  of  his  youth,  and  so  joins  the  ranks  of  the  sexual  mono- 
maniacs who  vainly  chase  the  will-o'-the-wisp,  sexual  gratification,  all  their 
lives.  Variations  of  early  impressions  may  determine  sexual  perversion 
rather  than  abnormally-powerful  desire.  Let  the  physician  who  has  the 
confidence  of  his  patients  inquire  into  this  matter,  and  he  will  be  surprised 
at  the  result.  Only  a  short  time  since,  one  of  the  author's  patients,  a  man 
of  exceptional  intellect,  volunteered  a  similar  explanation  for  his  own  ex- 
cesses. Satiety  also  brings  in  its  train  a  deterioration  of  normal  sexual  sen- 
sibility, with  an  increase,  if  anything,  in  the  sexual  appetite.  As  a  result, 
the  deluded  and  unfortunate  being  seeks  for  new  and  varied  means  of  grati- 
fication, often  degrading  in  the  extreme.  Add  to  this  condition  intem- 
perance or  disease,  and  the  individual  may  become  the  lowest  type  of  sexual 
pervert.  As  Hammond^  concisely  puts  it,  regarding  one  of  the  most  disgust- 
ing forms  of  sexual  perversion: — 

Pederasty  is  generally  a  vice  resorted  to  by  debauchees  who  exhaust  the  re- 
sources of  the  normal  stimulus  of  the  sexual  act,  and  who  for  awhile  find  in  this  new- 
procedure  the  pleasure  which  they  can  no  longer  obtain  from  intercourse  with  women. 

As  shown  in  the  preceding  chapter,  even  when  the  differentiation  of 
sex  is  complete  from  a  gross  physical  stand-point,  the  receptive  and  gener- 
ative centers  of  sexual  sensibility  may  fail  to  become  perfectly  differen- 

^Op.  cit. 


534:  SEXUAL    PEEYEESIOX   AXD    IX'YEESIOX. 

tiated.  The  result  under  such  circumstances  might  be,  upon  the  one  hand, 
sexual  apathy,  and,  upon  the  other,  an  approximation  to  the  female  or  male 
type,  as  the  case  may  be.  Such  a  failure  of  development  and  imperfect 
differentiation  of  structure  would  necessarily  be  too  occult  for  discovery 
by  any  physical  means  at  our  command.  It  is,  however,  only  too  readily 
recognizable  by  its  results. 

There  exists  in  every  great  city  so  large  a  number  of  sexual  perverts 
that  seemingly  their  depraved  tastes  have  been  commercially  appreciated  by 
the  demi-monde.  This  has  resulted  in  the  formation  of  establishments  whose 
principal  business  it  is  to  cater  to  the  perverted  sexual  tastes  of  a  numerous 
class  of  patrons.  Were  the  names  and  social  positions  of  these  patrons  made 
public  in  the  case  of  most  of  our  large  cities,  society  would  be  regaled  with 
something  fully  as  disgusting,  and  coming  much  nearer  home,  than  the 
Pall  Mall  Gazette  exposures. 

The  individuals  alluded  to  would  undoubtedly  resent  the  appellation 
of  "sexual  pervert";  but,  nevertheless,  in  many  instances  they  present  the 
disease  in  its  most  inexcusable  form:  tbat  from  viciou?  impulse.  Person- 
ally, the  author  cannot  appreciate  any  difference,  from  a  moral  stand-point, 
between  the  individual  who  is  gratified  sexually  only  by  oral  masturbation 
performed  by  the  opposite  sex  and  those  unfortunate  mortals  whose  passions 
can  be  gratified  only  by  performing  the  active  role  in  the  same  disgusting 
performance.  One  is  to  be  pitied  for  his  constitutional  fault;  the  other  to 
be  despised  for  -his  deliberately-acquired  debasement.  The  professional 
jDrostitute  who  panders  to  the  depraved  sexual  tastes  of  certain  male  speci- 
mens of  the  genus  homo  has,  at  least,  the  questionable  excuse  of  commercial 
instinct,  and  in  some  cases  the  more  valid  one  of  essential  sexual  perver- 
sion.   These  excuses  the  majority  of  her  patrons  certainly  dp  not  have. 

An  interesting  theory,  bearing  upon  the  question  of  sexual  perversion 
in  its  relations  to  evolutionary  reversion,  is  advanced  by  Clevenger^: — 

A  paper  on  "Eesearches  into  the  Life-history  of  the  Monads,"  by  W.  H. 
Dallinger,  F.R.M.S.,  and  J.  Drysdale,  M.D.,  was  read  before  the  Eoyal  Microscopical 
Society,  on  December  3,  1873,  wherein  fission  of  the  monad  was  described  as  being 
preceded  by  the  absorption  of  one  form  by  another.  One  monad  would  fix  on  the  sarcode 
of  another,  and  the  substance  of  the  lesser  or  under  one  would  pass  into  the  upper 
one.  In  about  two  hours  the  merest  trace  of  the  lower  one  was  left,  and  in  four 
hours  fission  and  multiplication  of  the  larger  monad  beg-an."  Professor  Leidy  has 
asserted  that  the  ameba  is  a  cannibal,  whereupon  Michels^  calls  attention  to  Dallinger 
and  Drysdale's  contribution,  and  draws  therefrom  the  inference  that  each  cannibalistic 
act  of  the  ameba  is  a  reproductive  or  copulative  one,  if  the  term  is  admissible. 

At  first  glance  such  a  suggestion  seems  ludicrous  enough;  but  a  little  consider- 
ation will  show  that,  in  thus  fusing  two  desires,  we  have  still  to  g-et  at  the  meaning 


^  "Physiology  and  Psychology,"  1885. 

-  A  full  description  of  this  interesting  phenomenon  may  be  found  in  the  Monthly 
Microscopical  Journal   (London),  for  October,  1877. 
^  American  Journal  of  Microscopy,  July,  1877. 


EELATIOX    OF    SEXUAL    DESIEE    TO    HUXGEE.  535 

and  derivation  of  tlie  primary  one — desire  for  food.  The  cannibalistic  ameba  may,  as 
Dallinger's  monad  certainly  does,  impregnate  itself  by  eating  one  of  its  own  kind,  and 
we  have  innumerable  instances,  among  algae  and  protozoa,  of  this  sexual  fusion's  ap- 
pearing vei-y  much  like  ingestion.  Crabs  have  been  seen  to  confuse  the  two  desires  by 
actually  eating  portions  of  each  other  while  copulating;  and,  in  a  recent  number  of  the 
Scientific  American,  a  writer  details  the  Mantis  7-eligiosa  female  eating  off  the  head 
of  the  male  mantis  during  conjugation.  Some  of  the  female  aracJmidce  find  it  neces- 
sary to  finish  the  marital  repast  by  devouring  the  male,  who  tries  to  scamper  away 
from  his  fate.  The  bitings  and  even  the  embrace  of  the  higher  animals  appears  to 
have  reference  to  this  derivation.  It  is  a  physiologic  fact  that  association  often 
transfers  an  instinct  in  an  apparently  outrageous  manner.  With  quadrupeds  it  is 
most  clearly  olfaction  that  is  most  related  to  sexual  desire  and  its  refiexes;  but  not 
so  in  man.  Ferrier  diligently  and  vainly  searched  the  region  of  the  temporal  lobe 
near  its  connection  with  the  olfactory  neiwe  for  the  seat  of  sexuality;  but,  with  the 
diminished  importance  of  the  smelling  sense  in  man,  the  faculty  of  sight  has  grown  to 
vicariate  olfaction;  certainly  the  "lust  of  the  eyes'  is  greater  than  that  of  other 
special  sense-organs  among  bimana. 

In  all  animal  life  multiplication  proceeds  from  growth,  and  until  a  certain  stage 
of  growth,  puberty,  is  reached,  reproduction  does  not  occur.  The  complementary 
nature  of  growth  and  reproduction  is  observable  in  the  large  size  attained  by  some 
animals  after  castration.  Could  we  stop  the  division  of  an  ameba,  a  comparable  in- 
crease in  size  would  be  effected.  The  grotesqueness  of  these  views  is  due  to  their 
novelty,  not  to  their  being  unjustifiable.  While  it  must  thus  seem  apparent  that  a 
primeval  origin  for  both  ingestive  and  sexual  desire  existed,  and  that  each  is  a  true 
hunger,  the  one  being  repressible  and  in  higher  animal  life  being  subjected  to  more 
control  than  the  other,  the  question  then  presents  itself:  Wliat  is  hunger?  It  re- 
quires but  little  reflection  to  convince  us  of  its  potency  in  determining  the  destiny  of 
nations  and  individuals  and  what  a  stimulus  it  is  in  animated  creation.  It  seems 
likely  that  it  has  its  origin  in  the  atomic  affinities  of  inanimate  nature,  a  view  mon- 
istic enough  to  please  Haeckel  and  Tyndall. 

Spitzka,^  in  commenting  on  the  foregoing,  says: — 

There  are  some  observations  made  by  alienists  which  strongly  tend  to  confirm 
Clevenger's  theory.  It  is  well  known  that,  under  pathologic  circumstances,  rela- 
tions, obliterated  in  higher  development  and  absent  in  health,  return  and  simulate 
conditions  found  in  lower,  and  even  in  primitive,  forms.  An  instance  of  thi^  is  the 
pica,  or  morbid  appetite  of  pregnant  women  and  hysteric  girls  for  chalk,  slate- 
pencils,  and  other  articles  of  an  earthy  nature.  To  some  extent  this  has  been  claimed 
to  constitute  a  sort  of  reversion  to  the  oviparous  ancestry,  which,  like  the  birds  of 
our  day,  sought  the  calcareous  material  required  for  the  shell-structure  in  their  food. 
There  are  forms  of  mental  perversion  properly  classed  under  the  head  of  the  degener- 
ative mental  states  in  which  a  close  relation  between  the  hunger  appetite  and  sexual 
appetite  becomes  manifest. 

Under  the  heading  "Wollust,  Mordlust,  AntliropopJiagie,"  Kraf!t-Ebing 
describes  a  form  of  sexual  perversion  where  the  snfEerer  fails  to  find  grati- 
fication unless  he  or  she  can  bite,  eat,  murder,  or  mutilate  the  mate.  He 
refers  to  the  old  Hindoo  myth,  Civa  and  Durga,  as  showing  that  such  ob- 
servations in  the  sexual  sphere  were  not  unknown  to  the  ancient  races.  He 
gives  an  instance  where,  after  the  act,  the  ravisher  butchered  his  victim  and 


^  Science,  June  25,  1881. 


536  SEXUAL    PERVEESION   AND    INVERSION. 

would  have  eaten  a  piece  of  the  viscera;  another  where  the  criminal  drank 
the  blood  and  ate  the  heart;  still  another,  where  certain  parts  of  the  body 
were  cooked  and  eaten. ^  Nature  (London),  commenting  on  Kiernan's 
article,  quotes  Ovid:  '^Mulieres  in  coitu  nonnemque  genas  cervicemque  maris 
mordunt." 

Illustrations  of  the  varying  types  of  sexual  perversion  are,  of  late 
years,  finding  their  way  into  literature.  A  very  interesting  series  of  cases 
of  inverted  sexuality  is  reported  by  Krafft-Ebing,^  which  vividly  demon- 
strate the  psychic  peculiarities  of  their  class.  The  following  is  a  fair  type, 
save  in  the  fact  that  the  condition  was  in  nowise  betrayed  by  femininity 
of  'physique.    This  is  not  usual,  but  by  no  means  rare: — - 

Case  1.- — Mr.  X.,  merchant,  residing  at  the  time  in  America,  38  years  old, 
said  to  be  of  a  family  sound  in  mind  and  body,  affected  since  youth  with  neuras- 
thenic complaints,  otherwise  sound,  wrote  me  in  the  fall  of  1882  a  long  letter,  the 
most  important  parts  of  which  are  here  transcribed: — 

"I  have  read  your  article  in  the  Zeitschrift  fiir  Psychiatrie.  By  it  I  and 
thousands  of  others  are  rehabilitated  in  the  eyes  of  every  thinking  and  half-way-fair- 
minded  man,  and  I  give  you  my  heartiest  thanks  therefor.  You  well  know  how 
cases  like  mine  are  derided,  execrated,  and  persecuted.  I  well  understand  that  science 
has  taken  hold  of  this  matter  so  recently  that,  in  the  eyes  of  one  whose  mind 
is  sound  and  who  is  unversed  in  the  nature  of  this  disease,  it  appears  as  a  horrible 
and  unnatural  crime.  Ulrich  has  not  overestimated  the  prevalence  of  this  disease. 
In  my  own  city  (13,000  inhabitants)  I  personally  know  of  fourteen  cases,  and  in  a 
city  of  60,000  people  I  know  of  eighty. 

"I  will  take  the  liberty  of  encroaching  on  your  time  by  giving  a  short  sketch 
of  my  life,  and  shall  do  so  with  all  frankness.  It  will  perhaps  furnish  you  with 
data  for  your  critical  studies  of  this  malady.  You  may  make  such  use  of  these 
statements  as  you  see  fit  so  long  as  my  name  is  suppressed. 

"Music  and  literature  were  always  my  hobbies.  My  whole  disposition  is  femi- 
nine. I  hate  all  noise,  disturbance,  and  obscenity.  As  a  child,  I  associated  constantly 
with  girls  and  played  with  their  dolls  and  toy-kitchens.  I  liked  to  dress  in  girl's 
clothes  and  so  earned  the  nickname  of  'girl-lover'  ('maedchen-scMiecker') .  Aftenvard, 
when  I,  became  a  student  and  took  part  in  turning  and  gymnastics,  it  was  still  my 
delight  to  help  my  mother  in  her  household  duties.  At  the  age  of  thirteen  I  arrived 
at  puberty, — that  is,  I  acquired  a  fondness  for  another  being;  but  it  was  for  one 
of  my  own  sex.  At  school  I  always  had  my  lover  and  was  horribly  jealous  of  any 
young  girl  or  school-mate  toward  whom  he  showed  any  preference.  My  delight  was 
to  kiss  him,  while  my  sense  of  propriety  overcame  my  sexual  desires,  though  to 
gratify  them  was  the  very  goal  of  my  wishes.  You  will  be  surprised  to  learn  that 
until  I  was  twenty-eight  years  of  age  I  never  had  a  seminal  emission,  either  through 
involuntary  emissions,  onanism,  or  by  performing  the  sexual  act  with  a  man. 

"While  still  a  young  man  I  had  a  serious  love-affair  with  a  sophomore.  He 
returned  my  love  in  a  way,  but  only  with  the  enthusiastic  friendship  of  a  boy.    Once, 


^  "Ueber  gewisse  Anomalien  des  Geschlechtstriebes,"  von  Krafft-Ebing,  Archiv 
fiir  Psychiatrie,  vii.  It  is  unnecessary  to  call  attention  to  the  logic  of  Kiernan's 
deductions  from  the  above  as  applied  to  the  Whitechapel  horrors.  ("Sexual  Perver- 
sion and  the  Whitechapel  Murders."  J.  G.  Kiernan,  Medical  Standard,  November, 
1888.) 

-  "Psychopathia  Sexualis." 


PECULIARITIES    OF    SEXUAL    PERVERTS    AND    INVERTS.  537 

when  we  happened  to  be  sleeping  together  and  my  member  became  sexually  excited, 
he  naively  asked  me  if  I  took  him  for  a  girl.  I  ventured  only  to  kiss  him  and  he 
returned  my  kisses.  In  the  manner  of  youths  we  raved  over  poetry  and  literature. 
Our  parting  was  for  me  almost  heart-breaking.  The  young  ladies  in  the  house  of 
my  master  where  I  lived  had  no  effect  upon  me.  I  associated  Avith  them  in  a  friendly, 
but  entirely  dispassionate,  manner. 

"Xew,  but  entirely  Platonic,  love-affairs  with  young  men  followed;  but  although 
the  outward  appearances  were  most  agreeable,  there  often  came  over  me  the  de- 
pressing thought- — you  are  not  like  other  men — and  this  troubled  me  most  when  I 
was  in  a  circle  of  laughing,  joking  comrades  who  were  full  of  animal  spirits  and 
sometimes  indulged  in  licentious  pleasures.  I  did  not  know  whether  I  should  laugh 
or  cry.  It  was  an  almost  unbearable  condition,  and  I  was  forced  constantly  to 
throw  sand  in  the  eyes  of  others  and  to  act  contrary  to  my  inclinations.  I  was 
out  of  this  dilemma  only  when  in  the  society  of  those  like  myself;  it  was  therefore 
necessary  for  me  to  seek  the  society  of  those  whom  it  would  have  been  more  ad- 
visable for  me  to  have  avoided.  I  never  found  in  the  society  of  beautiful  women 
that  invigoration  of  the  mental  powers  which  is  commonly  the  case,  but  did  find  it 
among  fascinating  young  men.  I  prefer  to  associate  with  married  women  or  entirely 
innocent  and  ingenuous  young  ladies.  Every  attempt  to  draw  me  into  the  matri- 
monial net  disgusts  me,  and  on  the  question  of  marriage  I  am  sensitive  to  a  ridiculous 
degree. 

"Until  I  was  twenty-eight  years  old  I  had  no  suspicion  that  there  were  others 

constituted   like  myself.     One   evening   in   the   castle-garden   at  X ,   where,   as   I 

subsequently  found,  those  constituted  like  myself  were  accustomed  to  seek  and  find 
each  other,  I  met  a  man  who  powerfully  excited  my  sexual  feelings,  so  much  so 
that  I  had  a  seminal  emission.  With  that  I  lost  my  better  manhood  and  came  often 
to  the  park  and  sought  similar  places  in  other  cities. 

"You  will  readily  conceive  that  Avith  the  knowledge  thus  acquired  there  came  a 
sort  of  comfort — the  satisfaction  of  association  and  the  sense  of  no  longer  being 
alone  and  singular.  The  oppressive  thought,  that  I  was  not  as  others  were,  left  me. 
The  love-affairs  which  now  followed  gave  my  life  a  certain  zest  which  I  had  never 
known  before.  But  I  was  only  hurrying  to  my  fate.  I  had  formed  an  intimate 
acquaintance  with  a  young  man.  He  was  eccentric,  romantic,  and  frivolous  in  the 
extreme  and  without  means.  He  obtained  complete  control  over  me  and  held  me  as 
if  I  were  his  legal  wife.  I  was  obliged  to  take  him  into  business.  Scenes  of  jealousy 
which  are  scarcely  conceivable  took  place  in  my  house.  He  repeatedly  made  attempts 
at  suicide  with  poison  and  it  was  with  difficulty  that  I  saved  his  life.  I  suffered 
terribly  by  reason  of  his  jealousy,  tyranny,  obstinacy,  and  brutality.  When  jealous 
he  would  beat  me  and  threaten  to  betray  my  secret  to  the  authorities.  I  was  kept 
in  constant  suspense  lest  he  should  do  so.  Again  and  again  I  was  obliged  to  rid  my 
house  of  this  openly  insane  lover  by  making  large  pecuniary  sacrifices.  His  passion 
for  me  and  his  shameless  avarice  drove  him  back  to  me.  I  was  often  in  utter 
despair  and  yet  could  confide  my  troubles  to  no  one.  After  he  had  cost  me  10,000 
francs,  and  a  new  attempt  at  extortion  had  failed,  he  denounced  me  to  the  police. 
I  was  arrested  and  charged  with  having  sexual  relations  with  my  accuser,  who  was 
as  guilty  as  myself.  I  was  condemned  to  imprisonment.  My  social  position  was 
totally  destroyed,  my  family  brought  to  sorrow  and  shame,  and  the  friends  who  had 
heretofore  held  me  in  high  esteem  now  abandoned  me  with  horror  and  disgust.  That 
was  a  terrible  time!  And  yet  I  had  to  say  to  myself:  'You  have  sinned — yes, 
grievously  sinned — against  the  common  ideas  of  morality,  but  not  against  Nature.' 
A  thousand  times  no!  A  part  of  the  blame  at  least  should  fall  upon  the  antiquated 
law  which  would  confound  with  depraved  criminals  those  who  are  forced  by  nature 
to  follow  the  inclinations  of  a  diseased  and  perverted  instinct. 


538  SEXUAL    PEEVEESIOX    AND    INVERSION, 

"You  may  get  an  idea  of  how  natural  and  spontaneous  our  actions  are  from 
the  following  incident:  — 

"About  two  years  ago  I  was  with  a  friend  in  a  company  of  jovial  acquaint- 
ances. A  bright^  fun-loving  young  lady  whom  I  might  well  have  a  passion  for,  but 
who,  as  a  woman,  made  no  impression  whatever  upon  me,  dressed  herself  in  the 
uniform  of  an  officer  with  moustache,  etc.  From  the  minute  when  she  entered  the  room 
in  this  metamorphosis!  felt  a  sexual  passion  toward  her. 

"A  friend  once  advised  me  to  marry  and  dress  my  wife  in  male  attire.  I  know 
of  a  case  in  Geneva  where  an  admirable  attachment  between  two  men  like  myself  has 
existed  for  seven  years.  If  it  were  possible  to  have  a  pledge  of  such  a  love  they  might 
well  make  pretensions  to  marriage,  but  in  the  absence  of  that  the  proposal  of  Ulrich 
seems  laughable  indeed.  One  thing  is  true.  Our  loves  bear  as  fair  and  noble  flowers, 
incite  to  as  praiseworthy  efforts  as  does  the  love  of  any  man  for  the  woman  of  his 
affections.  There  are  the  same  sacrifices,  the  same  joy  in  abnegation  even  to  the 
laying  down  of  life,  the  same  pain,  the  same  joy,  sorrow,  happiness,  as  with  men  of 
ordinary  natures. 

"I  will  add  that,  so  far  as  I  can  judge,  I  am  of  perfect  physical  build,  and  that 
there  is  nothing  remarkable  as  regards  my  sexual  organs.  My  walk  and  voice  are 
masculine,  and  one  would  never  suspect  me  to  be  what  I  have  described,  while  many 
of  my  class  betray  themselves  by  their  expression,  downcast  eyes,  gait,  posture, 
bending  of  the  body,  manner  of  sitting,  or  dress. 

"In  consequence  of  the  disgrace  that  came  upon  me  in  my  fatherland  I  am 
obliged  to  reside  in  America.  Even  now  I  am  in  constant  anxiety  lest  what  befel 
me  at  home  should  be  discovered  here  and  thus  deprive  me  of  the  respect  of  my 
fellow-men. 

"May  the  time  soon  come  when  science  shall  educate  the  people  so  that  they 
shall  rightly  judge  our  unfortunate  class;  but  before  that  time  can  come  there  will 
be  many  victims." 

The  following  case  of  Krafft-Ebing's  is  an  excellent  illustration  of  in- 
verted sexuality  in  the  female.  It  is  a  t}q3e  that  is  quite  familiar  to  all 
students  of  the  ^Dsycholog}^  of  sex: — 

Case  2. — Miss  X,  38  years  old,  consulted  me  in  the  fall  of  1881  regarding 
severe  spinal  irritation  and  chronic  insomnia,  for  which  she  had  extensively  used 
chloral  and  morphine. 

Her  mother  was  of  a  nervous  organization;  the  rest  of  the  family  apparently 
healthy.  Her  sufferings  dated  from  a  fall  upon  the  back  received  in  1872,  which 
caused  the  patient  a  severe  shock.  In  connection  therewith  there  developed  neuras- 
thenic and  hysteric  symptoms  with  severe  spinal  irritation  and  insomnia.  Episodically 
there  was  hysteric  paraplegia  of  eight  months'  duration  and  instances  of  hysteric 
hallucinatory  delirium  with  convulsions.  In  addition  there  were  symptoms  of  mor- 
phinism. A  stay  of  several  months  in  the  clinic  removed  these  and  also  materially 
alleviated  the  neurasthenic  condition.  These  gratifying  results  were  in  great  part 
accomplished  by  general  faradism. 

At  her  first  appearance  the  patient  attracted  attention  by  her  clothing,  features, 
man's  hat,  short  hair,  spectacles,  gentleman's  cravat  and  a  sort  of  coat  of  male  cut 
covering  her  woman's  dress.  She  had  coarse  male  features,  a  rough  and  rather  deep 
voice,  and,  with  the  exception  of  the  bosom  and  female  contour  of  the  pelvis,  looked 
more  like  a  man  in  woman's  clothing  than  like  a  woman.  During  all  the  time  I 
had  her  under  observation  there  were  no  signs  of  eroticism.  When  I  spoke  about 
her  clothing  she  said  she  wore  it  because  it  was  convenient. 


I 


PECULIAEITIES    OF    SEXUAL    PEKYEETS    AND    INVEKTS.  539 

I  incidentally  discovered  that  as  a  child  she  had  a  fondness  for  horses  and 
masculine  pastimes,  but  never  took  any  interest  in  feminine  occupations.  She  later 
developed  a  taste  for  literature  and  sought  to  fit  herself  for  a  teacher.  She  never 
enjoyed  dancing,  and  the  ballet  had  no  interest  for  her.  Her  highest  enjoyment  was 
to  go  to  the  circus.  Up  to  the  time  of  her  sickness  in  1872  she  had  no  particular 
fondness  for  persons  of  either  sex.  After  this  there  developed  in  her  an  attachment 
toward  women,  especially  young  women.  She  was  never  passionately  aroused  in  her 
intimacy  with  them,  but  her  friendship  and  self-sacrifices  toward  those  she  loved 
was  boundless,  while  from  that  time  on  she  had  abhorrence  for  men  and  male  society. 
Her  relatives  informed  me  that  the  patient  had  an  offer  of  marriage  in  1872,  but 
refused  it.  She  took  a  trip  to  a  Avatering-place  and  returned  entirely  changed  sexually, 
and  made  use  of  expressions  which  implied  that  she  did  not  consider  herself  to  be 
a  woman.  Since  then  she  would  only  associate  with  women,  had  love-affairs  with 
them,  and  let  fall  insinuations  that  she  was  a  man.  Her  passion  for  women  showed 
itself  in  tears,  fits,  jealousy,  etc.  While  she  was  at  the  baths  in  1874  a  young 
woman  fell  in  love  with  her,  thinking  she  was  a  man  in  woman's  clothing.  When  this 
young  lady  afterward  married,  Miss  X  became  very  melancholy  and  complained  of 
faithlessness.  Her  friends  noticed  that  after  her  sickness  she  evinced  a  decided  prefer- 
ence for  male  clothing  and  a  masculine  appearance,  while  before  her  illness  she  had 
been  in  nowise  other  than  a  womanly  character,  at  least  as  regard  her  sexual  feelings. 

Further  investigations  showed  that  the  patient  was  carrying  on  a  purely  Platonic 
love-affair  with  a  young  woman  and  Avrote  her  tender  love-letters. 

The  foregoing  case  is  a  type  that  is  very  frequently  met  with  in  women. 
It  is  by  no  means  necessary  that  tlie  female  should  be  masculine  in  phy- 
sique, however.  In  such  relatively-mild  cases  she  often  is  not.  TsTor  is  it 
necessary  that  physical  indulgence  of  a  perverted  character  should  occur; 
it  often  does  not  go  beyond  the  psychic  phase.  Favoring  circumstances  will 
inevitably  produce  the  extreme  result,  however.  Parents,  sociologic  stu- 
dents, physicians,  and  educators  should  understand  this. 

The  medico-legal  importance  of  a  recognition  of  such  cases  was  shown 
by  the  Mitchell- Ward  murder  at  Memphis  some  years  since. 

Tardieu^  chronicles  the  following  interesting  points  with  regard  to  one 
form  of  sexual  perversion: — 

I  do  not  pretend  to  explain  that  which  is  incomprehensible,  and  thus  to  penetrate 
into  the  causes  of  pederasty.  We  can  nevertheless  ask  if  there  is  not  something  else 
in  this  vice  than  a  moral  perversion,  than  one  of  the  forms  of  psyclwpatMa  sexualis, 
of  which  Kaan  has  traced  the  history.  Unbridled  debauchery,  exhausted  sensuality, 
can  alone  account  for  pederastic  habits  as  they  exist  in  married  men  and  fathers 
of  families,  and  reconcile  with  the  desire  for  women  the  existence  of  these  impulses 
to  unnatural  acts.  We  can  form  some  idea  on  the  subject  from  a  perusal  of  the 
writings  of  pederasts  containing  the  expression  of  their  depraved  passions.  Casper 
had  in  his  possession  a  journal  in  Avhieh  a  man,  member  of  an  old  family,  had 
recorded,  day  by  day,  and  for  several  years,  his  adventures,  his  passions,  and  his 
feelings.  In  this  diary  he  had,  with  unexampled  cynicism,  avowed  his  shameful 
habits,  which  had  extended  through  more  than  thirty  years,  and  which  had  succeeded 
to  an  ardent  love  for  the  other  sex.  He  had  been  initiated  into  these  new  pleasures 
by  a  procuress,  and  the  description  which  he  gives  of  his  feelings  is  startling  in  its 


'Sur  les  attentats  aux  mceurs,"  Paris,  1858,  p.  125. 


540  SEXUAL    PEEVEESION   AND   INVEESION. 

intensity.    The  pen  refuses  to  write  of  the  orgies  depicted  in  this  journal,  or  to  repeat 
the  names  which  he  gave  to  the  objects  of  his  love. 

I  have  had  frequent  occasion  to  read  the  correspondence  of  known  pederasts  and 
have  found  them  applying  to  each  other  under  the  forms  of  the  most  passionate  lan- 
guage, idealistic  names  which  legitimately  belong  to  the  diction  of  the  truest  and  most 
ardent  love.  But  it  is  difficult  not  to  admit  the  existence  in  some  cases  of  a  real  patho- 
logic alteration  of  the'  moral  faculties.  When  we  witness  the  profound  degradation, 
the  revolting  salacity  of  the  individuals  who  seek  for  and  admit  to  their  disgusting 
favors  men  who  are  gifted  both  with  education  and  fortune,  we  might  well  be  tempted 
to  think  that  their  sensations  and  reason  are  altered;  but  we  can  entertain  no 
doubt  on  the  subject  when  we  call  to  mind  facts  such  as  those  I  have  had  related 
to  me  by  a  magistrate,  who  has  displayed  both  ability  and  energy  in  the  pursuit  of 
pederasts.  One  of  these  men,  who  had  fallen  from  a  high  position  to  one  of  the 
lowest  depravity,  gathered  about  him  the  dirty  children  of  the  streets,  knelt  before 
them  and  kissed  their  feet  with  passionate  submission  before  asking  them  to  yield 
themselves  to  his  infamous  propositions.  Another  experienced  singularly  voluptuous 
sensations  by  having  a  vile  wretch  inflict  violent  kicks  on  his  gluteal  region.  What 
other  idea  can  we  entertain  of  such  hoiTors  than  that  those  guilty  of  them  are 
actuated  by  the  most  pitiable  and  shameful  insanity? 

Some  of  the  manifestations  of  sexual  perversion^  quoted  by  various  au- 
thorities, are  very  extraordinarj^,  and  it  is  difficult  to  associate  them  with 
titillations  of  sexual  sensibility.  Perhaps  the  most  familiar  of  these  cases 
is  that  of  Sprague,  who  was  committed  in  Brooklyn  many  years  ago  for 
highway  robbery.^  It  is  unnecessary  to  present  this  case  in  detail,  but  an 
outline  of  it  may  prove  interesting.  Sprague  was  arrested  immediately 
after  having  assaulted  a  young  lady  by  throwing  her  down,  violently  re- 
moving one  of  her  shoes  and  running  away  with  it.  He  made  no  attempt 
to  steal  anything  else,  although  she  had  on  valuable  jewelry.  When  the 
trial  came  on,  insanity  was  alleged  as  a  defence.  Numerous  witnesses,  the 
principal  of  whom  was  the  father  of  the  defendant,  a  clergyman  of  the 
highest  respectability,  testified  to  the  erratic  conduct  of  the  prisoner.  A 
family  history  was  elicited  which  bore  most  pertinently  upon  Sprague's 
case,  his  grandfather,  grandmother,  great-granduncle,  three  great-aunts, 
and  a  cousin  having  been  insane.  He  had  himself  in  his  youth  received 
numerous  blows  and  falls  upon  the  head,  and  within  a  year  from  the  last 
head-injury  he  had  developed  severe  headaches,  associated  with  which  his 
friends  noted  a  bulging  of  the  eyes.  About  this  time  the  prisoner  developed 
a  fondness  for  stealing  and  hiding  the  shoes  of  females  about  the  house,  and 
it  was  found  necessary  by  his  relatives  and  the  female  domestics  to  carefully 
conceal  or  lock  up  their  shoes  to  prevent  his  abstracting  them.  Upon  in- 
vestigation it  was  discovered  that  the  act  of  stealing  or  handling  the  shoes 
produced  in  him  sexual  gratification. 

Wharton-  some  years  ago  chronicled  a  most  peculiar  case  of  sexual  per- 
version.   In  this  instance  the  morbid  sexual  desire  impelled  the  individual 


1  Beck,  "Medical  Jurisprudence,"  vol.  i,  1860,  p.  732. 

2  «^  Treatise  on  Mental  Unsoundness,"  etc.,  Philadelphia,  1873. 


UNIQUE    CASES    OF    SEXUAL    PEEVEKSION"   AND    INVEESION.  541 

to  assault  young  girls  upon  the  streets  of  Leipzig  by  grasping  them  and 
plunging  a  small  lancet  into  their  arms  above  the  elbow.  The  fact  was  de- 
veloped after  his  arrest  that  these  peculiar  acts  of  assault  were  accompanied 
by  seminal  emissions.  This  authentic  case  gives  a  vivid  coloring  to  the 
rational  hypothesis  that  the  notorious  Whitechapel  assassin  was  a  sexual 
pervert. 

Many  cases  of  sexual  perversion  manifest  themselves  only  under  the 
influence  of  disease  or  drunkenness.  Ovarian  irritation  and  those  obscure 
cases  of  hysteria  in  women  which  we  are  unable  to  trace  to  a  definite 
physical  cause  are  frequently  associated  with  sexual  perversion.  The 
physiologic  (?)  disturbance  incidental  to  pregnancy  is,  in  certain  neurotic 
patients,  productive  of  similar  aberration.  "Whether  the  influence  of  liquor 
obtunds  the  moral  faculties  or  develops  an  inherent  defect  of  sexual  physi- 
ology in  any  given  case  is,  of  course,  difficult  to  determine.  The  author 
knows  of  an  individual  who  co-nducts  himself  with  perfect  propriety  when 
sober,  and  who  is  a  man  of  exceptional  intellect,  but  who,  when  tinder  the 
influence  of  alcohol,  is  too  low  for  consort  with  the  human  species. 

Some  of  the  cases  of  sexual  perversion  that  have  come  under  the  au- 
thor's observation  have  been  quite  as  unique  as  that  of  Sprague's  or  the  case 
related  by  Wharton.  In  one  instance  a  man  who  frequented  houses  of  ill 
fame  found  it  impossible  to  qualify  sexually  until  a  chicken  had  been  de- 
capitated. The  sight  of  the  struggling,  bleeding  fowl  was  eminently  aphro- 
disiac in  his  case.  Under  no  other  circumstances  was  it  possible  for  him  to 
secure  an  erection.  In  another  case  the  pervert  was  in  the  habit  of  renting 
a  full  set  of  regal  robes,  crown  and  all.  These  he  would  put  upon  the  object 
of  his  attention.  Having  seated  the  woman  upon  an  improvised  throne,  he 
would  besiege  (?)  his  ready-made  queen  until  his  object  was  attained.  Ego- 
mania was  evidently  a  dominant  phase  of  the  sexual  psychopathy  of  this 
particular  case. 

Heredity,  on  the  one  hand,  and  acquired  disease  or  injury,  on  the  other, 
sometimes  bear  a  very  important  relation  to  sexual  psychopathy.  A  very 
interesting  case  bearing  on  both  these  etiologic  factors  was  reported  by 
Urquhart^ : — 

Case. — Young  man,  26  years  of  age,  of  medium  height  and  weight  and  fairly- 
robust  development,  was  sentenced  to  one  year's  imprisonment  at  hard  labor  as  a 
punishment  for  immoral  practices.  The  judge  in  passing  sentence  remarked  that  while 
it  might  not  be  the  logical  course  of  treatment,  it  was  the  only  thing  to  do,  for  he 
was  not  legally  insane,  and  if  set  at  liberty  would  only  go  on  with  his  vicious  prac- 
tices. The  heredity  in  this  case  was  exceptionally  bad.  The  father  was  a  drunkard 
and  roue.  He  was  syphilitic  and  died  young.  The  mother  was  also  syphilitic — in- 
fected by  the  father  during  her  pregnancy.  Subject's  only  sister  was  a  prostitute,  but 
his  only  brother  was  decent  and  respectable.  When  a  small  boy,  subject  fell  over  a 
staircase,  striking  on  his  head  and  injuring  his  skull.     He  became  unconscious,  with 


^  Journal  of  Mental  Science,  January,  1891. 


542  SEXUAL    PERVERSION   AND    INVERSION. 

bleeding  at  the  ears.  His  mother  noticed  thereafter  a  great  change  in  his  conduct. 
At  school  he  soon  became  a  confirmed  masturbator,  and  showed  a  marked  amorous 
preference  for  male  children.  It  Avas  finally  discovered  that  it  was  unsafe  to  permit 
other  boys  to  be  in  his  company.  His  sexuality  toward  the  opposite  sex  was  per- 
verted, and  women  in  general  disgusted  him.  His  habits  toward  his  own  sex  finally 
attracted  the  attention  of  the  police,  because  of  which  he  attempted  to  kill  himself. 
He  Avas  finally  apprehended,  tried,  and  sentenced  to  prison. 

A  peculiar  ease  was  reported  by  A.  E.  Eeynokls/  of  a  man  who  liacl  a 
love-affair  with  a  woman  whose  right  lower  extremity  had  been  amputated  at 
the  thigh,  and  became  so  much  attached  to  her  that  he  was  afterM^ard  im- 
potent with  perfectly-formed  women,  it  being  necessary  for  him  to  secure 
females  who  had  undergone  mutilation  similar  to  that  of  his  former  attach- 
ment in  order  that  he  might  be  sexually  gratified. 

A  peculiar  phase  of  sexual  perversion  is  occasionally  seen  among  mas- 
turbators,  male  and  female.  The  individuals  suffering  from  this  have  a 
peculiar  predilection  for  titillating  the  sexual  organs  in  various  outlandish 
fashions.  Such  patients  are,  in  many  instances,  particularly  fond  of  intro- 
ducing foreign  bodies  of  various  kinds  into  the  urethra  and  thus  gratifying 
their  sexual  desires.  Such  cases  occur  even  among  persons  who  have  op- 
portimities  for  normal  gratification.  Thus,  an  interesting  case  is  reported 
by  Poulet  of  a  married  woman,  the  mother  of  three  children,  who  failed  to 
receive  gratification  from  ordinary  intercourse,  and  practiced  masturbation 
with  a  blunt  piece  of  wood  fastened  to  a  wire.  Her  unfortunate  failing  was 
exposed  through  the  slipping  of  the  foreign  body  from  her  grasp  into  the 
bladder.  Kiernan  reports  a  somewhat  similar  case  of  an  insane  girl  who 
was  admitted  into  his  service  at  the  Cook  County  Insane  Asylum.  In  this 
instance  the  physical  appearance  of  the  sexual  organs  and  anus  led  to  a 
suspicion  of  pederasty,  which  was  confirmed  upon  investigation. 

The  association  of  sexual  perversion  with  malformations  of  the  sexual 
organs  with  or  without  associated  close  approximation  to  the  general  phy- 
sique of  the  opposite  sex,  male  or  female,  as  the  case  may  be,  is  certainly 
not  surprising.  The  author  has  met  with  some  most  peculiar  illustrations 
of  this  form  of  sexual  perversion.  The  relation  of  both  physical  and  psychic 
defects  of  sexual  differentiation  to  sexual  perversion  has  been  expatiated 
upon  in  the  preceding  chapter. 

Treatment. — The  treatment  of  sexual  perversion  is  highly  unsatis- 
factory, largely  from  the  fact  that  the  abnormality  of  sexual  instinct  is  due 
to  defective  sexual  differentiation — psychic  or  organic,  or  both.  To  the 
average  pervert,  his  or  her  condition  seems  normal.  The  victim  recognizes 
the  fact  that  he  differs  from  the  usual  standard  of  sexual  normality,  but 
he  is  absolutely  incapable  of  reasoning  out  his  defect  from  any  other 
stand-point.    He  often  desires  to  be  cured  of  his  abnormal  sexuality — only, 


^  Transactions  of  the  Chicago  Medical  Society. 


TEEATMENT    OF    SEXUAL    PEKVEESION   AND    INVEESIOIsr.  543 

however,  by  the  substitution  of  the  instinct  which  seems  common  to  those 
about  him.  There  is  no  innate  repugnance  to  his  own  condition,  which 
is  as  normal  to  his  own  mind  as  is  a  confusion  of  colors  to  the  color- 
blind. He  knows  his  abnormal  sexuality  only  from  study  and  comparison 
of  normal  individuals.  He  regrets  his  social  ostracism,  while  really  seeing 
nothing  wrong  in  the  condition  that  has  brought  it  about.  Taking  into 
consideration  the  congenital  character  of  most  cases,  the  difficulty  of  cure 
is  self-evident.  Where  there  is  physically  imperfect  differentiation  of  sex, 
the  case  is  absolutely  hopeless.  Perversion  from  impressions  of  an  abnormal 
psychosexual  character  made  while  the  sexual  function  is,  so  to  speak,  in 
its  plastic,  formative  stage,  perversions  due  to  functional  neuropathic  dis- 
turbances, and  perversions  from  vice,  are  often  susceptible  of  cure.  Thera- 
peutic suggestion  is  of  paramount  importance  in  most  cases.  Psycho- 
therapy is  the  key-note  of  treatment.    As,  Kiernan  so  tersely  says: — 

Insistence  on  the  morbidity  of  the  pervert  ideas^  and  prohibition  of  sexual 
literature  as  in  the  sexual  neurasthenic,  together  with  allied  psychic  therapy  and 
anaphrodisiac  methods  cannot  but  benefit.  These  patients,  like  the  hysteric,  will  not 
"will"  to  be  cured  while  they  axe  subjects  of  sympathy. 

It  has  long  been  the  author's  belief  that  a  large  proportion  of  both 
boys  and  girls  may  be  easily  converted  into  sexual  perverts  by  unnatural 
sexual  impressions  at  or  about  the  age  of  pubert}^,  when  the  centers  of  sex- 
ual receptivity  and  impulse  are  in  a  plastic  state.  It  is  strange  that  phy- 
sicians did  not  discover  this  earlier.  The  sexual  dangers  of  boarding-schools 
were  long  ago  pointed  out  by  a  French  novelist,  x\dolphe  Belot.^  A  word  of 
warning,  therefore,  may  not  be  out  of  place. 

For  the  insane  pervert  the  asylum  is  the  only  recourse.  In  rare  in- 
stances of  perversion,  castration,  oophorectomy,  and  clitoridectomy  are 
worth  consideration. 


'Mdlle.  Giraud,  Ma  Femme.' 


CHAPTEK  XXIV. 

Satyriasis,  XYiiPHOMAxiA,  Mastuebatiox,  Sexual  Excess, 

AND    UnPHTSIOLOGIC    CoITUS. 
SATYEIASIS. 

Satyriasis  is  a  disease  that  occurs  in  the  male,  with  or  without  insanity, 
the  principal  manifestation  of  which  is  an  abnormally  excessive  and  un- 
reasonable sexual  desire.  It  is  not  a  frequent  disease  as  brought  to  the  at- 
tention of  the  physician,  probably  because  the  opportunities  for  gratification 
of  the  male  are  relatively  numerous.  The  disease  consists  of  constant  desire, 
attended  with  vigorous,  often  painful,  erections,  which  in  some  instances 
no  amount  of  sexual  intercourse  will  relieve.  It  has  been  termed  "erotic 
delirium,'^  and  it  may  or  may  not  be  due  to  coarse  disease  of  the  brain.  In 
the  worst  cases  the  unfortunate  individual  may  be  the  subject  of  mania  and 
delirium  of  a  violent  form.  William  Acton^  relates  the  case  of  an  old  man, 
suffering  from  satyriasis,  whose  desire  was  so  extreme  that  he  would  mas- 
turbate whenever  he  was  brought  into  the  presence  of  women.  After  his 
death  a  small  tumor  was  found  in  the  pons  Varolii.  Shocks  and  injuries  in- 
volving the  cerebellum  are  peculiarly  apt  to  be  followed  by  persistent  erec- 
tions. This  phenomenon  has  been  noticed  in  subjects  executed  by  hanging. 
Injuries  of  the  spinal  cord,  although  in  the  majority  of  instances  inhibiting 
the  sexual  function  by  producing  complete  paralysis  of  that  portion  of  the 
cord  which  seems  to  bear  an  intimate  relation  to  sexual  sensibility — the 
genito-spinal  center — produce  in  some  instances,  from  irritation  of  the  same 
nervous  structure,  persistent  erection.  Cases  of  this  kind  are  related  by 
Lallemand.-  The  following  case  is  one  that  has  been  very  frequently 
quoted: — 

Case. — ^The  subject  was  a  soldier,  who,  in  climbing  over  the  walls  of  the  garri- 
son, fell  upon  his  sacrum.  Following  this  injury  he  became  paraplegic  and  suffered 
with  persistent  priapism.  This  lasted  for  some  time,  and  could  not  be  relieved  by 
intercourse.  All  pleasurable  sensations  and  the  power  of  ejaculation  were  destroyed, 
although  sexual  desire  was  very  ardent.  During  sleep,  however,  the  unfortunate 
subject  had  lascivious  dreams,  accompanied  by  slight  sensation  and  ejaculation. 

The  causes  of  satyriasis,  as  enumerated  by  different  authorities,  are: 
masturbation;  disease  of  the  brain,  particularly  those  affecting  the  cere- 
bellum; injuries  and  diseases  of  the  spinal  cord,  sexual  excesses,  and  the 
administration  of  poisonous  doses  of  cantharides.    Prolonged  continence  is 


^  "On  the  Eeproductive  Organs." 
^  "On  Spermatorrhea." 

(544) 


SATYRIASIS   AND   NYMPHOMANIA.  5i5 

another  rare  and  dubious  cause  to  which  satyriasis  has  been  ascribed.     J. 
W.  Howe/  quoting  from  Blandet,  describes  a  case  of  this  kind: — 

Case. — The  patient  was  an  earnest,  hard-working,  and  zealous  missionary.  He 
was  unfortunate  in  the  possession  of  an  intensely  passionate  nature,  although  he  had 
not  gratified  himself  in  a  vicious  manner.  So  intense  was  his  excitement  in  the  pres- 
ence of  women  that  it  became  necessary  to  seclude  himself  from  them  so  far  as  pos- 
sible. This  plan  proved  a  failure,  for  he  became  so  much  worse  that  he  suffered  from 
satyriasis  in  an  extreme  degree.  A  cure  was  finally  accomplished  by  the  normal  in- 
dulgence of  his  passion. 

The  mild  form  of  excessive  sexual  desire  called  priapism  may  be  due 
to  local  irritation.  In  some  instances  such  irritation  will  produce  severe 
priapism  without  sexual  desire.  The  author  has  at  present  under  treatment 
a  gentleman  who  is  suffering  in  this  manner: — 

Case. — The  patient  is  50  years  of  age,  has  been  somewhat  dissipated  and  a  high 
liver,  as  a  consequence  of  which  he  has  gout  in  an  extreme  degree.  He  has  suffered 
for  several  years  from  vesical  irritation,  attributed  by  him  to  stricture  of  long  standing. 
The  urethra  on  examination  presents  no  abnormality;  the  urine  is  highly  concentrated 
and  strongly  acid.  As  soon  as  the  patient  retires  for  the  night  he  begins  to  be  troubled 
with  severe  erections  that  are  so  vigorous  as  to  be  quite  painful  and  which  persist 
during  the  entire  night.     Sexual  intercourse  gives  no  relief. 

This  case  can  only  be  attributed  to  sexual  hyperesthesia  incidental  to 
long-continued  gout  and  irritation  of  the  genito-urinary  tract.  This  does 
not  manifest  itself  during  the  day-time,  but  during  the  night,  when,  as  is 
well  known,  the  spinal  cord  is  relatively  hyperemic  and  in  a  condition  of  in- 
creased functional  activity.  The  same  explanation  hold  goods  here  as  in 
nocturnal  emissions,  which  will  be  discussed  later. 

NYMPHOMANIA. 

Nymphomania  (erotomania,  furor  uterinus)  is  a  disease,  analogous  to 
satyriasis,  occurring  in  the  female.  It  is  characterized  by  excessive  and 
inordinate  sexual  desire,  and  very  often  by  the  most  pronounced  lewdness 
and  vulgarity  of  speech  and  action.  In  the  most  severe  forms  it  is  apt  to 
be  associated  with,  and  dependent  upon,  other  forms  of  insanity,  with  or 
without  gross  brain  disease.  In  some  instances  the  disease  is  a  reflex  mani- 
festation of  irritative  affections  of  the  sexual  apparatus.  Thus,  ovarian  and 
uterine  diseases  are  apt  to  be  associated  with  it.  Any  irritation  of  the  ex- 
ternal genital  organs  in  females  of  hysteric  temperament  may  produce  the 
affection,  all  that  is  necessary  being  a  nervous  and  excitable  state  of  the 
nervous  system,  a  passionate  temperament,  and  local  irritation  of  the  sen- 
sitive sexual  apparatus.  Some  of  the  recorded  cases  of  nymphomania  are 
very  pitiful.  It  has  been  known  to  be  associated  with  the  cerebral  disturb- 
ance incidental  to  pulmonary  consumption.    Thus,  a  case  has  been  recorded 

^  "Excessive  Venery." 


546  ETIOLOGY   OF    NYMPHOMANIA. 

of  a  woman  in  the  last  stages  of  this  disease  who  exhibited  the  most  inor- 
dinate sexual  desire,  and  a  short  time  before  her  death  importuned  her 
husband  to  have  intercourse  with  her.  The  association  of  hysteria  with 
this  unfortunate  psychosexual  condition  is  one  with  which  nearly  every 
gynecologist  of  experience  is  perfectly  familiar. 

Nymphomania  is  also  known  to  occur  as  a  result  of  masturbation  and 
sexual  excess.  In  women  of  a  highly  erethistic  temperament  it  has  de- 
veloped as  a  consequence  of  sudden  cessation  of  the  normal  method  of 
sexual  indulgence. 

Knowledge  or  experience  in  sexual  matters  is  by  no  means  necessary 
to  the  development  of  nymphomania,  for  it  has  been  known  to  occur  in 
individuals  who  had  neither  masturbated  nor  indulged  in  sexual  inter- 
course. Some  of  the  most  painful  cases  of  the  disease  have  occurred  during 
pregnancy.  The  principal  astonishing  feature  of  such  unfortunate  cases  is 
the  acquirement  of  lewd  actions  and  expressions  on  the  part  of  women  pre- 
viously and  naturally  pure-minded  and  refined.  Such  women  may  use  ex- 
pressions and  indulge  in  actions  that  lead  the  physician  to  wonder  where 
they  could  possibly  have  acquired  a  knowledge  of  them. 

The  gynecologist  is  compelled  to  be  on  his  guard  with  reference  to  a 
not-infrequent  form  of  nymphomania,  but  one  which  is  little  suspected  by 
those  surrounding  the  patient,  in  which  the  woman  develops  a  fondness  for 
gynecologic  manipulations.  The  subterfuges  and  devices  of  such  patients 
to  induce  handling  of  the  sexual  organs  by  the  physician  are  often  remark- 
able. One  of  the  most  frequent  forms  of  this  malingering  is  the  pretense 
of  retention  of  urine,  although  every  disease  that  they  ever  heard  of  may 
be  complained  of  by  such  patients  in  their  insane  endeavors  to  obtain 
manipulations  at  the  hands  of  the  physician. 

Howe  relates  an  interesting  case  of  this  kind  occurring  under  his  ob- 
servation at  Bellevue  Hospital: — 

Case. — A  girl,  aged  18,  was  admitted,  supposed  to  be  suffering  from  retention  of 
urine.  She  was  thin;  her  eyes  were  deep-set,  but  bright  and  staring,  and  were  found 
filled  with  tears.  Her  statement  was  that  she  had  passed  no  water  for  three  days;  that 
she  was  subject  to  these  attacks  and  was  treated  by  having  her  water  drawn  off.  I  in- 
troduced the  catheter,  and  found  only  a  few  ounces  of  urine  in  her  bladder,  not  enough, 
indeed,  to  corroborate  her  history.  The  next  morning,  as  she  had  not  urinated  during 
the  night,  I  drew  off  the  urine  again.  While  doing  so  I  noticed  by  a  series  of  peculiar 
convulsive  movements  that  she  was  under  the  influence  of  strong  excitement.  Further 
examination  showed  that  the  labia  minora,  clitoris,  and  adjacent  parts  were  red  and 
swelled  and  bathed  in  a  profuse  mucous  secretion.  I  then  remembered  that  on  the  pre- 
vious evening  she  had  shown  a  somewhat  similar  state  of  excitement,  and  gave  the  nurse 
orders  to  watch  her  closely  all  day.  In  the  evening  the  nurse  informed  me  that  the 
patient  kept  up  a  constant  friction  of  the  genitals  when  she  supposed  no  one  was 
watching,  and  even  when  eyes  were  on  her  she  endeavored  by  uneasy  movements  in 
the  bed  to  continue  the  titillation.  Knowing  then  what  I  had  to  deal  with,  the 
patient  was  given  a  sedative  and  told  that  she  must  empty  her  bladder  without 
assistance.    For  thirty-six  hours  subsequently  she  obstinately  insisted  on  her  inability 


MASTURBATIOISr.  547 

to  urinate.  When  she  was  told  no  catheter  would  be  employed  again  there  was  no 
further  retention.  Soon  after  she  left  the  hospital  I  learned  that  a  physician  friend 
of  mine  was  treating  her  for  uterine  disorder,  but  he,  too,  soon  found  out  the  true 
nature  of  the  case,  and  advised  her  to  get  married. 

.  A  number  of  cases  of  a  similar  nature  have  come  nnder  the  author's 
observation,  both  in  hospital  experience  and  private  practice. 

The  treatment  of  satyriasis  and  nymphomania  consists  chiefly  in  the 
removal  of  irritation  of  the  sexual  apparatus,  the  administration  of  anaphro- 
disiac  remedies,  to  be  hereafter  considered,  and  attempts  to  restrain  sexual 
excesses,  or  to  break  the  habit  of  masturbation,  as  the  case  may  be.  Where 
there  is  actual  organic  disease  the  case  is  lOvely-to  be  found  to  be  incurable 
in  the  majority  of  instances,  particularly  if  the  structural  disease  involves 
the  nervous  centers.  In  women,  extirpation  of  the  ovaries  or  the  procedure 
of  Mr.  Baker  Brown — clitoridectomy — may  be  performed.  Howe  recom- 
mends the  application  of  the  actual  cautery  to  the  back  of  the  neck.  Basing 
this  treatment  upon  the  theory  that  the  disease  takes  its  origin  in  overex- 
citation of  the  nerve-fibers  of  the  cerebellum  or  some  of  the  ganglia  in  the 
neighborhood,  he  also  suggests  blisters  and  setons  as  answering  the  same 
purpose.  Dry  cupping  to  the  nucha  is  also  serviceable.  Means  to  restore 
the  general  health  are  always  indicated.  In  the  severe  cases  of  the  maniacal 
form  of  excessive  sexual  desire  the  asylum  is  usually  our  only  recourse, 
though  castration  is  occasionally  effective.  Castration,  however,  is  a  remedy 
to  be  suggested  with  the  greatest  caution.  There  has  latterly  been  a  tend- 
ency to  recommend  this  operation  in  various  conditions  without  duly 
weighing  the  responsibility  involved. 

MASTUEBATION. 

Masturbation — often  erroneously  styled  onanism — consists  in  the  pro- 
duction of  the  venereal  orgasm  by  some  mechanic  means  other  than  normal 
sexual  congress — usually  by  manual  friction.  Perverted  methods  of  sexual 
contact  properly  come  under  a  different  head. 

The  habit  of  masturbation  is  very  common,  especially  in  the  male. 
The  larger  proportion  of  young  lads  become  addicted  to  it,  sooner  or  later, 
to  a  greater  or  less  degree,  and  it  is  far  more  common  in  adult  life  than  is 
generally  believed.  The  habit  sometimes  persists  after  marriage,  even  where 
the  individual  is  potent.  Cases  of  this  kind  have  come  under  the  author's 
observation.  Eegarding  the  prevalence  of  the  practice,  it  is  probable  that 
few  boys  escape  it;  indeed,  competent  authorities  have  asserted  that  the 
man  who  can  truthfully  say  that  he  has  never  masturbated  is  a  rara  avis. 

Fortunately  for  the  comparative  reputation  of  the  human  species  for 
intelligence  and  decency,  masturbation  is  met  with  in  the  lower  animals. 
Bulls,  dogs,  cats,  monkeys,  and  domestic  fowls  have  been  known  to  practice 
it.    Howe  claims  that  in  such  instances  the  animals  have  received  pernicious 


548  MASTUEBATIOX    IN   INFANTS. 

training  from  degraded  human  beings,  but  students  of  natural  histor}'  are 
not  likel}'  to  agree  with  this  view.^ 

Masturbation  is  peculiarly  a  vice  of  civilized  humanity.  Precocious 
jjassions,  incidental  to  an  immoral  and  sexually-exciting  environment,  asso- 
ciated with  a  defective  will-jDower  and  degenerate  nerve-constitution  follow 
in  the  wake  of  civilization.  The  restrictions  put  upon  sexual  indulgence 
in  civilized  social  systems  are  such  that  the  fear  of  consequences  deter  both 
the  male  and  female  from  sexual  indulgence.  There  is  no  restriction  of  op- 
portunities for  masturbation  and  no  social  penalties;  hence  the  individual 
deems  himself  privileged  to  indulge  as  he  sees  fit.  The  influences  to  which 
boys  especially  are  subjected  are  of  the  worst  sort.  Erotic  books,  pictures, 
newsj)aper  nastiness,  vile  plays,  and  the  counsel  and  example  of  depraved 
associates — often  of  adult  age — tend  to  keep  the  sexual  organs  in  a  per- 
jjetual  condition  of  excitement.  Curiosity  is  often  a  factor  in  the  etiology 
of  masturbation.  Accidental  friction  of  the  genitals  develops  the  interest- 
ing fact  that  pleasurable  sensations  are  thereby  elicited.  The  result  is  ob- 
vious. Many  boys  are  led  into  the  habit  by  the  teachings  of  depraved  adults 
who  convey  the  impression  to  the  easily  influenced  mind  of  the  susceptible 
and  curious  boy  that  the  seminal  discharge,  however  produced,  is  necessary 
to  the  preservation  of  manl}'  health. 

It  is  claimed  that  ver}^  joimg  children — even  infants  at  the  breast — 
have  been  known  to  masturbate.  In  such  cases  the  term  masturbation  is 
hardly  applicable.  Very  young  children  do  not  experience  the  venereal 
orgasm  and  emission,  and  mere  titillation  of  the  genitalia  cannot  fairly  be 
pronounced  masturbation.  Irritation  of  the  genitalia  often  impels  children 
to  rub  the  parts  in  the  endeavor  to  obtain  relief.  In  some  instances  the 
hands  are  used  and  in  others  the  thighs  are  spasmodically  rubbed  together. 
The  sensation  thereby  elicited  is  probably  pleasurable  to  a  degree,  corre- 
sponding, perhaps,  to  that  experienced  by  scratching  or  rubbing  areas  af- 
fected by  pruritus  in  any  location.  That  pleasurable  sensations  may  be 
elicited  by  genital  friction  when  the  parts  are  presumably  in  a  normal  con- 
dition is  shown  by  the  fact  that  nurses  not  infrequently  deliberately  handle 
the  genitals  for  the  purpose  of  quieting  the  crying  child. 

The  influence  of  genital  irritation  in  impelling  children  to  handle  the 
genitals  is  well  shown  in  vesical  calculus.  The  elongated  prepuce  resulting 
from  boys  with  vesical  calculus  tugging  at  the  penis  in  a  vain  effort  to  ob- 
tain relief  from  reflex  penile  pain  is  sufficiently  familiar. 

The  great  danger  of  genital  irritation  in  children  is  that  the  friction 
induced  for  its  relief  may  continue  until  a  precocious  sexual  sensibility  is 
developed,  which  prolongs  the  habit  of  genital  titillation  until  puberty  ar- 
rives and  true  masturbation  supervenes.     A  fact  not  generally  recognized 


^  "Excessive  Venery,"  etc.,  Joseph  W.  Howe.  What  would  have  been  Howe's 
opinion  of  the  case  of  a  young  heifer  who  allowed  the  approach  of  the  bull  at  any 
and  all  times,  in  season  and  out  of  season? 


MASTUEBATION    IN    INFANTS.  549 

is  the  precocious  development  of  puberty  as  a  consequence  of  the  frequent 
and  long-continued  stimulation  of  the  parts. 

The  sources  of  irritation  that  serve  to  direct  the  child's  attention  to  its 
genitals  may  be  direct  or  reflex.  Among  the  direct  causes  are  such  condi- 
tions as  intertrigo,  eczema,  phimosis,  balanitis,  and  the  contact  of  highly- 
acid  urine.  Phimosis,  and  the  consequent  retention  of  irritating  secretions, 
is  the  most  potent  and  frequent  direct  source  of  irritation.  A  long  prepuce, 
even  when  not  phimosed,  is  also  a  fertile  source  of  trouble.  The  principal 
reflex  causes  of  genital  irritation  in  children  are  vesical  calculus  and  AscU' 
rides  recti. 

Pseudo-emissions  finally  characterize  infantile  attempts  at  masturba- 
tion as  the  subject  approaches  puberty.  The  discharge  is  at  first  composed 
only  of  urethral  and  prostatic  mucus  combined  with  the  secretion  of  the 
glands  of  Cowper.  This  discharge  is  attended  by  a  more  or  less  typic 
orgasm.  After  puberty  is  established — whether  precociously  or  not — the 
discharge  gradually  assumes  the  properties  of  seminal  fluid — imperfectly 
elaborated,  it  is  true,  yet  containing  the  characteristic  spermatozoa.  If  the 
habit  be  persisted  in,  the  semen  is  never  perfectly  elaborated,  but  is  thin 
watery,  and  contains  relatively  few  spermatozoa. 

The  prevalent  custom  of  alloAving  children  to  sleep  together  is  often 
responsible  for  the  inculcation  of  vicious  habits;  this  is  especially  true  when 
great  disparity  of  ages  exists,  for  a  precocious  or  vicious  boy  or  girl  ap- 
proaching puberty  is  sure  to  contaminate  the  morals  of  every  child  with 
AA'hom  he  or  she  is  brought  in  intimate  contact.  Parents  should  be  taught 
to  regard  every  intimate  attachment  of  their  offspring  for  other  children  as 
worthy  of  distrust,  and  this  warning  is  especially  justifiable  in  cities. 
Country  children,  with  their  excellent  jjhysique  and  many  opportunities  for 
the  diversion  of  their  superfluous  animal  spirits,  are  proportionatel}^  less 
likely  to  become  vicious;  then,  too,  they  are  not  so  apt  to  be  taught  vice  by 
lewd  persons  of  more  advanced  years. 

Primary  sexual  precocity  constitutes  a  foundation  for  many  cases  of 
masturbation.  This  sexual  precocity  may  be  due  (1)  to  heredity  and  (2)  to 
the  causes  of  local  irritation  already  mentioned.  Persons  of  an  extraordi- 
narily amative  disposition,  who  indulge  excessively  in  sexual  intercourse, 
are  apt  to  procreate  children  who  are  not  only  feeble  in  physique  and  in- 
tellect, but  possessed  of  premature  sexual  desire.  It  has  been  claimed,  and 
apparently  with  justice,  that  children  of  illegitimate  parentage  are  particu- 
larly apt  to  develop  sexual  precocity.  Premature  sexual  desire  is  sometimes 
associated  with  a  precocious  development  of  the  sexual  organs.  Mr.  South, 
an  English  surgeon,  some  years  ago  reported  a  case  of  a  child,  20  months 
old,  in  whom  the  penis  was  larger  than  the  average  adult  organ,  the  pubes 
being  covered  with  hair.  This  extraordinary  freak  was  addicted  to  mas- 
turbation. 

Female  children  may,  through  uncleanliness,  become  confirmed  mas- 


550  MASTUKBATION    IX    WOMEIST. 

turbators.  This  should  be  imjiressed  upon  the  minds  of  mothers  whenever 
compatible  with  delicacy.  Filth  is  quite  apt  to  accumulate  about  the  female 
genitals,  and  with  the  addition  of  highly  acid,  or,  perhaps,  decomposed,  nrine 
may  produce  great  irritation.  Eubbing  the  genitals  is  natural  under  such 
circumstances,  with  the  usual  lamentable  results.  The  amount  of  titillation 
necessary  to  produce  an  orgasm  in  some  highly  erethistic  females  is  often 
surprisingly  slight.  The  author  has  met  with  several  cases  that  demon- 
strate this.  One,  a  single  Avoman  of  23,  had  only  to  will  that  an  orgasm 
occur,  in  order  to  perform  masturbation,  and  the  slightest  touch  upon  the 
genitals  when  she  was  sexually  excited  produced  the  desired  result.  An- 
other subject,  a  girl  of  IT,  masturbated  several  times  a  da}'  by  simply  rub- 
bing the  thighs  together.  Still  another  young  woman  has  an  orgasm  when- 
ever she  attempts  to  run  a  sewing  machine.  The  use  of  this  appliance  is 
especially  apt  to  produce  uterine  congestion  and  irritation,  with  coincident 
sexual  excitement,  as  every  competent  gynecologist  knows.  In  many  cases 
of  masturbation  among  women  pelvic  disease  is  directly  responsible  for  the 
vice;    hence  some  cases  must  be  regarded  in  a  more  than  charitable  light. 

It  is  unfortunate  that  we  have  so  few  opportunities  for  determining  the 
frequency  of  masturbation  among  women  and  female  children,  for,  although 
the  female  sex  is  much  less  vicious  than  the  male,  the  vice  is  probably  often 
responsible  for  nervous  and  local  gynic  disease.  Women  resent  any  allusion 
to  their  sexual  functions,  and  mothers  will  usually  hate  the  physician  most 
cordially  if  he  so  much  as  suggests  the  possibility  of  their  children's  mas- 
turbating. They  will  usually  believe  what  is  said  of  other  children,  but  as 
to  their  own,  that  is  quite  a  different  matter.  A  short  time  since  a  lady 
brought  a  young  relative  to  the  author  regarding  some  painful  trouble  with 
the  sexual  organs.  The  child  was  only  eight  years  of  age,  yet  it  was  pre- 
cociously developed,  and  hair  had  already  appeared  upon  the  pubes  and 
labia  majora.  The  ostium  vaginte  was  dilated,  the  hymen  pouched  inward; 
the  nymphfe  enlarged,  reddened,  and  bathed  with  mucus;  and  the  clitoris 
larger  than  in  most  women.  The  slightest  touch  upon  the  parts  caused 
the  clitoris  to  become  erect,  and  the  involuntary  movements  of  the  child's 
limbs  showed  plainly  the  nature  of  the  trouble.  To  say  that  the  mother 
resented  the  diagnosis  would  be  putting  it  mildly.  Xeither  false  modesty 
nor  the  fear  of  resentment  on  the  part  of  parents  should  deter  the  phy- 
sician from  his  plain  duty  in  these  delicate  matters.  It  is  a  discouraging 
fact  that  it  is  difficult  to  impress  these  jjoints  upon  parents.  Whether  this 
be  due  to  their  cerebral  density  or  oversentitive  recollection  of  their  own 
evil  ways  is  a  question  difficult  to  answer. 

Young  girls — and,  upon  the  average,  women — are  naturally  much 
purer  minded  than  the  male  sex,  and  their  associations  are  not  apt  to  be 
such  as  tend  to  lower  the  moral  tone.  "When  the  female  becomes  corrupted 
it  is  usually  through  the  efEorts  of  the  opposite  sex,  and  not  through  the  in- 
fluence of  members  of  their  own,  although  the  corrujDt  woman  is  especially 


MASTURBATION    IN    WOMEN    AND    BOYS.  551 

dangerous  to  her  chaster  sisters.  There  are,  of  course,  many  exceptions  to 
the  rule,  especially  in  boarding-schools,  which  are  sources  of  especial  dan- 
ger to  both  sexes.  The  female  sexual  organs  are  less  exposed  than  the  male, 
and  in  the  performance  of  the  natural  function  of  urination  are  not  handled, 
as  is  necessary  with  the  male.  Females  are  consequently  less  likely  to  dis- 
cover accidentally  that  pleasurable  sensations  may  be  excited  by  manipula- 
tion of  these  organs,  and  thus  be  led  into  masturbation.  After  the  age  of 
puberty  the  female  is  protected  from  sexual  desire  to  a  certain  extent  by 
the  periodic  relief  afforded  to  the  generative  apparatus  through  the  physio- 
logic function  of  menstruation.  The  sexual  excitement  attendant  upon  the 
beginning  of  menstruation  is  usually  speedily  relieved  by  the  normal  flow; 
even  if  it  is  not,  it  is  obvious  that  manipulation  of  the  organs  is  not  apt  to 
be  practiced  at  that  time.  When  the  flow  ceases,  spontaneous  sexual  excite- 
ment has  usually  disappeared,  and  does  not  again  recur  until  the  next  men- 
strual epoch.  This  point  should  be  taken  into  special  consideration.^  In 
the  case  of  the  male  the  organs  are  not  only  handled  during  micturition, 
but  they  are  apt  to  obtrude  themselves  at  times  when  the  mind  is  entirely 
free  from  sexual  thoughts.  The  distension  of  the  bladder  with  the  urine 
accumulated  during  the  night  is,  for  example,  likely  to  produce  vigorous 
erections  in  the  morning.  Such  erections,  although  not  primarily  depend- 
ent upon  sexual  excitement,  are  very  apt  to  divert  the  mind  in  the  direction 
of  sexual  matters,  and  so  tempt  to  manipulation. 

Certain  kinds  of  gymnastic  exercise  are  productive  of  voluptuous  sen- 
sations that  may  lead  to  masturbation.     Howe  says-: — 

These  exercises  are  common  in  gymnasiums  and  school-grounds.  My  attention 
was  first  called  to  this  subject  by  the  history  of  a  masturbator.  He  entered  school 
at  the  age  of  seven.  The  next  day  he  visited  the  school-gymnasium.  Noticing  the 
swinging  pole,  he  took  hold  with  the  rest  of  the  boys,  swinging  himself  around  the 
circle  for  some  time.  In  a  few  minutes  he  had  such  peculiar  sensations  about  the 
genitals  that  he  had  to  stop  and  rest.  Again  and  again  he  swung  himself  around, 
with  the  same  effect,  the  sensations  becoming  more  positive  and  intense.  The 
tingling  sensations  finally  terminated  in  an  orgasm.  This  led  him  to  a  closer  exami- 
nation of  his  organs  and  new  methods  of  excitement,  until  he  became  a  confirmed 
masturbator. 

Exercises  involving  climbing,  swinging,  and  sliding  are  especially  per- 
nicious; yet  healthy  boys  may  indulge  moderately  in  them  without  evil 
results.  A  robust  boy  is  not  apt  to  thus  injure  himself,  as  might  a  lad  of 
less  animal  vigor  and  muscular  strength.  A  ca'rdinal  point  in  training  boys 
should  be  to  avoid  perineal  strain  and  friction,  and  swinging  exercises  that 
produce  vertigo  and  heighten  cerebellar  sensibility,  until  the  muscles  gen- 


^  In  a  general  way  it  may  be  asserted  that  girls  who  masturbate  are  degenerates, 
bearing  the  same  relation  to  normally  constituted  girls  that  nyphomaniacs  do  to 
normal  adults. 

'  Op.  cit. 


552  MASTUEBATION   AND    SEXUAL   EXCESS. 

erally  have  been  well  trained,  and  then  to  indulge  in  sucli  exercises  with 
great  moderation  at  tirst.  Many  boys  experience  vohiptnous  sensations 
while  climbing,  but  they  are  usually  delicate  lads.  The  author  has  known 
a  boy  to  fall  from  a  tree  and  experience  a  broken  arm  because  of  an  orgasm 
while  climbing. 

Both  young  and  old  subjects  Avith  prostatic  irritation  are  apt  to  have 
an  orgasm  while  riding  horseback.  One  of  the  author's  patients  cannot 
ride  a  trotting  horse  on  this  accoimt.  This  man  has  been  a  masturbator^ 
and  latterly  experienced  gonorrheal  prostatitis  that  left  the  seat  of  sexual 
sensibility  very  hyperesthetic. 

Boys  of  studious  and  retiring  habits  are  most  apt  to  be  masturbators 
and  to  suffer  severely  from  its  effects.  Sedentary  and  intellectual  pursuits 
foster  an  hyperesthetic  condition  of  general,  as  well  as  sexual,  sensibility. 
The  active,  robust,  manly  boy  who  indulges  in  out-of-door  athletic  sports, 
hunting  and  so  on,  has  an  outlet  for  what  has  been  aptly  termed  the  "ef- 
fusive cussedness"  of  boy-nature,  and  is  not  apt  to  study  his  sexual  appa- 
ratus. Again,  if  he  acquires  the  habit,  he  breaks  it  off  sooner  by  virtue  of 
his  greater  will-power,  and  it  is  less  likely  to  do  him  permanent  injury  than 
his  more  delicate  and  intellectual  brother.  The  "mother's  boy,"  of  all 
others,  requires  watching. 

Obviously,  the  damage  produced  by  masturbation  is  more  marked  in 
the  male  than  in  the  female.  Much  vitality  is  consumed  in  the  frequently 
recurring  calls  for  a  restoration  of  a  highl3^-elaborated  and  complex  secre- 
tion like  the  semen.  In  the  female  the  act  produces  merely  a  succession  of 
nervous  shocks,  the  injury  produced  being  modified  by  the  nervous  resist- 
ance of  the  individual.  As  the  function  of  the  female  in  the  sexual  act  is 
comparatively  passive,  we  are  not  apt  to  be  consulted  regarding  its  effects 
in  after-life.  The  author  recalls  a  case,  however,  of  a  married  woman  who 
had  been  a  masturbator,  who  claimed  that  she  had  never  had  a  natural 
orgasm,  the  excitement  stopping  just  short  of  culmination. 

The  sexual  orgasm  has  been  likened  to  an  epileptic  attack,  which,  in 
truth,  it  greatly  resembles,  both  in  its  phenomena  and  effects.  The  mental 
hebetude  and  physical  prostration  folloAving  the  discharge  of  nerve-force 
characteristic  of  an  epileptic  attack  are  well  recognized.  The  sexual  orgasm 
is  analogous  to  epilepsy  in  that  it  aj)pears  to  be  attended  by  an  expenditure 
of  nerve-force,  followed  temporarily  by  a  certain  degree  of  nervous  prostra- 
tion with  disinclination  to  mental  exertion,  and  physical  lassitude.  Lalle- 
mand^  states  the  self-evident  fact  that  in  children  and  women  the  effects  that 
in  the  adult  male  are  termed  spermatorrhea  are  not  due  to  a  loss  of  semen, 
but  to  the  impression  made  by  the  orgasm  upon  the  nervous  system.  This 
he  terms  ehranlement  nerveux  epiJeptiforme.  This  is  similar  to  the  nervous 
exhaustion  produced  by  mental  excitement  or  convulsions,  the  latter  being 

^  Op.  cit. 


NATUEE  OF  THE  SEXUAL  OEGASM.  553 

especially  marked  in  yonng  susceptible  cliildren.  Tickling  produces  a  sim- 
ilar effect.  He  relates  a  case  in  which  a  fatal  result  was  produced  by  the 
effect  of  repeated  convulsive  shocks  upon  the  brain,  similar  to  those  re- 
ceived b}^  sensitive  subjects  from  tickling  the  soles  of  the  feet. 

The  venereal  orgasm,  therefore,  is  not  merely  local,  involving  pleas- 
urable sensations  and  the  evacuation  of  the  seminal  vesicles,  but  profoundly 
affects  the  whole  nervous  system.  So  important  is  the  relation  of  the  sexual 
act  to  the  general  nervous  system  that  it  is  only  mature  individuals  who 
can  bear  even  infrequent  acts  of  copulation  without  more  or  less  injury. 
In  young  persons  all  the  vital  powers  should  be  conserved  for  growth  and 
development. 

In  some  animals  the  epileptiform  character  of  the  sexual  orgasm  is 
very  prominent.  Writers  have  called  especial  attention  to  the  conduct  of 
the  male  rabbit,  who,  after  each  act  of  copulation,  falls  over  upon  his  side, 
the  whites  of  the  eyes  being  turned  up,  and  the  limbs  in  a  condition  of 
clonic  spasm.  Similar  phenomena  occur  in  some  other  animals,  and  are 
due  to  the  effect  on  the  spinal  cord  of  the  discharge  of  nerve-force.  The 
severity  of  the  impression  or  shock  upon  the  nervous  system  in  the  case  of 
the  human  subject  has  been  aptly  illustrated  in  those  occasional  instances 
of  sudden  death  during  or  after  copulation.  Apoplexy  and  paralysis  and 
fatal  cardiac  syncope  have  been  known  to  result  in  individuals  predisposed 
to  these  conditions,  as  a  consequence  of  the  sexual  orgasm. 

The  seat  of  sexual  sensibility  has  been  a  matter  of  some  dispute.  Some 
writers  claim  that  it  resides  principally  in  the  glans  penis.  Acton,  how- 
ever, questions  the  accuracy  of  this  theory,  relatLug  a  case  that  apparently 
contradicts  it,  as  follows: — 

Some  time  ago  I  attended  an  oflBcer  on  his  return  from  India  who  had  lost 
the  whole  of  the  glans  penis.  This  patient  completely  recovered  his  health,  the  parts 
healed,  and  a  considerable  portion  of  the  body  of  the  penis  was  left.  He  found,  to 
his  surprise,  that  the  sexual  act  was  not  only  possible,  but  that  the  same  amount 
of  pleasure  as  formerly  was  still  experienced.  He  assured  me,  indeed,  that  the  sexual 
act  differed  in  no  respect — so  far  as  he  could  detect — from  what  it  had  been  before 
the  mutilation.^ 

That  sexual  sensibility  is  not  limited  to  the  glans  penis  is  proved  by 
certain  masturbators  who,  failing  to  find  gratification  from  ordinary  manip- 
ulation, cause  the  orgasm  by  titillating  the  urethra.  In  Acton's  ease  it  is 
possible  that  the  patient  was  not  perfectly  normal  sexually  before  the 
mutilation. 

It  is  probable  that  through  external  impressions  transmitted  by  the 
eye,  ear,  and  touch,  the  sympathetic  system  assumes  a  special  sexual  func- 
tion.    It  is  incredible  that  sexual  impressions  are  transmitted  altogether 

^  It  would  be  interesting  to  know  the  final  result  in  this  case  of  Acton's.  Is  it 
not  analogous  to  those  cases  in  which,  after  amputation  of  the  arm  or  leg,  the  patient 
is  haunted  by  the  "ghost-hand"  or  foot  for  a  time? 


554  MASTUKBATION    Ais'D    SEXUAL    EXCESS. 

through  the  ordinal)^  sensitory  nerve-filaments.  It  is  Avell  known  that  emo- 
tional excitement  produces  a  profound  impression  upon  the  sympathetic 
nervous  system.  The  nervous  filaments  of  the  sympathetic  supplied  to  the 
generative  apparatus,  and  particularly  to  the  prostatic  sinus,  are,  in  all  prob- 
ability, the  principal  seat  of  sexual  sensibility.  It  is  possible  that  through 
their  infiuence  reflex  impressions  heighten  the  ordinary  sensibility  of  the 
part,  the  secretory  function  of  the  testes,  and  the  sensibility  of  the  prostatic 
sinus,  but  this  is  effected  also  through  the  sensitive  nerves  distributed  to  the 
delicate  mucous  membrane  of  the  glans  penis. 

Accumulation  of  blood  always  causes  a  gradual  augmentation  of  sensibility; 
but  in  this  case  the  glans  penis,  in  passing  from  a  non-erect  state  to  complete 
turgescence,  becomes  the  seat  of  a  completely  new  and  specific  sensibility,  up  to  this 
moment  dormant.  All  the  attendant  phenomena  react  on  the  nervous  centers.  From 
this  it  appears  that,  in  addition  to  the  nerves  of  general  sensibility,  which  fulfill  their 
functions  in  a  state  of  repose,  and  also  during  erection,  although  in  a  different 
manner,  there  must  be,  in  the  glans  penis,  special  nerves  of  pleasure  the  particular 
action  of  which  does  not  take  place  except  under  the  indispensable  condition  of  a 
state  of  erethism  of  the  glans.  When  this  is  over,  the  nerves  return  to  their  inaction 
and  remain  unaffected  under  all  ulterior  excitement.  They  are,  then,  in  the  same  con- 
dition as  the  remainder  of  the  generative  apparatus;  their  irritability  ceases  with 
the  consummation  of  the  act,  and,  together  with  this  irritability,  the  venereal  appe- 
tite ceases,  only  to  be  repeated,  with  the  same  resultant  phenomena,  at  each  new 
excitation. 

Symptoms  of  Masturhation. — The  alleged  characteristic  appearance  of 
the  masturbator  has  been  overestimated  by  the  reputable  physician,  as  well 
as  the  quack.  In  extreme  cases,  associated  with  other  causes  of  debility,  the 
masturbator  may  have  an  unmistakable  appearance,  but  in  the  majority  of 
cases  in  boys,  and  nearly  always  in  girls,  there  is  nothing  to  be  learned  from 
the  physiognomy.  Of  the  exceptional  cases  that  seem  to  present  certain 
peculiarities,  the  author  recognizes  two  classes,  viz.:  (1)  the  overgrown, 
clownish,  but  robust  lad,  with  sheepish  expression,  but  heavy,  almost  stupid 
intellect;  and  (2)  the  slender,  delicate,  and  intellectual  lad  of  refined  ways 
and  sensitive  nervous  temperament.  The  first  has  inevitably  a  greasy  skin, 
with  plentiful  acne,  but  excellent  color;  the  second,  a  sallow  or  pale  com- 
plexion and  sunken  eyes,  with  heavy  circles  about  them.  The  clownish  lad 
rarely  acknowledges  his  fault,  but  the  more  refined  lad  is  quite  apt  to  hint 
at  it  involuntarily  in  a  round-about  fashion,  especially  if  he  already  feels 
the  bad  effects  of  the  vicious  practice.  Unfortunately,  many  youths  will 
consult  the  doctor  on  some  trivial  pretext,  and  become  discouraged  because 
he  does  not  intuitively  detect  the  real  difficulty.  Young  lads  often  so  ex- 
press themselves  when  finally  confronted  with  a  direct  accusation. 

Acton  expresses  himself  on  the  effects  of  masturbation  as  follows^: — 

The  habit  causes  the  worst  physical  consequences.  At  first  there  is  little 
urethral  irritation.    Pain  may  occur  in  making  water,  with  a  frequent  desire  to  mictu- 


^  "The  Reproductive  Organs,"  etc.,  William  Acton. 


EFFECTS    OF    MASTUEBATIOISr.  555 

rate;  the  meatus  is  frequently  red;  and  ejaculation  previously  excited  only  by  much 
friction,  now  takes  place  immediately;  the  secretion  is  watery,  even  slightly  sanguino- 
lent,  and  emission  is  spasmodic.  A  sense  of  weight  is  felt  in  the  prostate,  perineum, 
or  rectum,  and  often  anomalous  pains  in  the  testes.  Nocturnal  emissions  become 
frequent,  and  easily  excited  by  erotic  dreams.  These  at  first  are  pleasurable,  but 
later  the  patient  is  only  made  aware  of  ejaculation  by  the  condition  of  his  linen. 
In  other  instances  the  semen  does  not  pass  away  in  jets,  but  flows  away  imperceptibly. 
In  some  cases  it  makes  its  way  back  into  the  bladder.  Other  patients  will  tell 
you  that  emissions  have  ceased,  but  on  going  to  stool,  with  the  last  drops  of  urine,  a 
quantity  of  viscid  fluid,  varying  from  a  drop  to  a  teaspoonful,  dribbles  from  the  end 
of  the  penis,  perhaps  containing  spermatozoa  in  greater  or  less  number. 

The  vicious  habit — having  impaired  the  growth,  health,  and  intellect  of  the 
patient — ceases  often  to  be  voluntarily  indulged  in,  because  no  longer  pleasurable. 
The  drain  on  the  system  during  defecation  or  micturition,  however,  continues,  and 
what  depended  at  first  on  artificial  excitement,  is  kept  up  by  irritation  or  inflamma- 
tion of  the  urethra,  vesiculse  seminales,  and  spermatic  ducts.  Too  frequent  irritation 
of  the  testes  causes  badly-formed  semen  to  be  secreted,  which  is  at  once  emitted. 
The  mucous  membrane  is  more  sensitive  than  usual,  acquiring  an  irritability  like 
that  often  seen  in  the  bladder,  and  which  irritability  appears  more  or  less  general. 
Pleasurable  sensations  seldom  attend  the  expulsion  of  ill-conditioned  semen,  overuse 
of  the  sensations  probably  causing  them  to  become  blunted.  The  patient  is  now 
frequently  reduced  to  complete  bodily  and  mental  impotence. 

The  majority  of  scientific  surgeons  will  hardly  accept  this  description 
of  the  effects  of  masturbation  as  applying  to  any  but  exceptional  cases. 
Obviously  it  is  often  difficult  to  determine  the  precise  relation  of  certain 
symptoms  to  masturbation.  While  the  quack  has  overdrawn  the  evils  of 
the  habit  from  purely  mercenary  motives,  respectable  medical  men  have 
been  too  much  inclined  to  go  to  the  other  extreme,  and  either  ignore  the 
subject  entirely  or  pass  it  by  as  a  matter  of  trivial  importance.  Mr.  Acton 
is  a  notable  exception  to  the  rule,  but  has,  perhaps,  presented  the  subject 
more  forcibly  than  it  deserves. 

Admitting  that  serious  effects  of  masturbation  are  relatively  rare,  its 
results  are  none  the  less  worthy  of  attention: — - 

The  first  effect  in  confirmed  cases  is  a  general  lack  of  tone  in  the  gen- 
erative apparatus.  The  penis  and  testes  are  relaxed  and  flabby,  and  the 
scrotum  pendulous;  varicocele  often  exists.  Great  sensitiveness  of  the 
urethra,  and  especially  of  the  prostatic  sinus  are  usual,  and  this  is  a  source 
of  pseudo-impotence  in  many  cases  by  producing  premature  ejaculation. 
According  to  Lallemand,  thickening,  degeneration,  and  often  atrophy  of 
the  ejaculatory  ducts,  seminal  vesicles,  and  seminal  tubules  are  sometimes 
seen.  Such  conditions  are  rare,  but  are  occasionally  to  be  observed  in  some 
cases  of  "masturbatory  insanity."  Prostatic  sensibility  is  generally  in- 
creased, and  confirmed  masturbators  are  likely  to  develop  prostatitis,  semi- 
nal vesiculitis,  cystitis,  or  epididymitis,  during  an  attack  of  gonorrhea. 

The  symptoms  of  masturbation  in  children  and  youths  are  by  no  means 
so  clear  as  some  authors  would  have  us  believe.  Thus  Lallemand  remarks 
as  follow^s: — 


556  MASTUEBATION    AND    SEXUAL   EXCESS. 

However  young  children  may  be,  they  get  thin,  pale,  and  irritable,  and  their 
features  become  haggard.  We  notice  the  sunken  eye,  the  long,  cadaverous-looking 
countenance,  the  downcast  look  which  seems  to  arise  from  a  consciousness  in  the  boy 
that  his  habits  are  suspected,  and,  at  a  later  period,  from  the  ascertained  fact  that  his 
virility  is  lost.  Habitual  masturbators  have  a  damp,  moist,  cold  hand,  very  charac- 
teristic of  great  vital  exhaustion;  their  sleep  is  short,  and  most  complete  marasmus 
comes  on;  they  may  gradually  waste  away  if  the  evil  passion  is  not  got  the  better 
of;  nervous  symptoms  set  in,  such  as  spasmodic  contraction,  or  partial  or  entire  con- 
vulsive movements,  together  with  epilepsy,  eclampsia,  and  a  species  of  paralysis 
accompanied  with  contractions  of  the  limbs. 

When  a  child,  who  has  once  shown  signs  of  a  great  memory  and  of  considerable 
intelligence,  is  found  to  evince  difficulty  in  retaining  or  comprehending  what  he  is 
taught,  we  may  be  sure  then  it  does  not  depend  upon  indisposition,  as  he  states,  or 
idleness,  as  is  generally  supposed.  Moreover,  the  progi^essive  derangement  in  his 
health  and  falling  off  in  his  activity  and  application  depend  upon  the  same  cause, 
the  intellectual  functions  becoming  enfeebled  in  the  most  marked  manner. 

While  there  is  some  consistency  in  Lallemand's  overdrawn  account 
of  the  appearance  and  physical  condition  of  the  masturbator,  the  cases  that 
it  will  fit  are  few  and  far  between.  As  a  matter  of  fact,  in  a  great  majority 
of  instances  of  masturbation  the  objective  effects  are  not  sufficiently  marked 
to  attract  attention.  Even  in  these  cases,  however,  a  permanent  impression 
may  be  made  upon  the  constitution  of  the  individual  by  virtue  of  which  he 
is  less  strongly  organized,  more  susceptible  to  disease,  and  less  capable  of 
entering  upon  the  battle  for  existence  than  boys  who  have  masturbated 
but  little,  if  at  all.  Sexual  capacity  and  enjoyment  in  after-life  may  be 
considerably  impaired  as  a  consequence  of  masturbation  in  youth,  although 
the  habit  may  have  made  no  physical  impression  sufficiently  pronounced 
to  attract  attention. 

Hyperesthesia  of  the  nerves  of  sexual  sensibility,  with  relaxation  of 
the  mouths  of  the  ejaculatory  ducts,  and  dilation  and  hypersecretion  of 
the  urethral  and  prostatic  follicles  are  frequent  results  of  masturbation. 
It  would  seem  that  the  overstimulation  and  frequent  emptying  of  the 
seminal  vesicles  incidental  to  the  vicious  habit  causes  them  to  acquire  in- 
tolerance of  their  contents;  this  results  in  nocturnal  emissions  and  pre- 
mature ejaculation,  during  normal  intercourse.  These  effects,  however, 
will,  in  the  majority  of  instances,  disappear  as  the  individual  grows  older, 
if  the  habit  be  discontinued,  although  it  is  probable  that  sexual  pleasure 
is  permanently  impaired  in  most  instances.  In  a  number  of  cases,  far  larger 
than  has  been  supposed,  chronic,  persistent  inflammation  of  the  seminal 
vesicles  results,  with  incidental  sexual  derangements  and  neurasthenia. 

As  regards  the  prognosis  in  children,  Lallemand  remarks  as  follows: — 

In  respect  to  the  evil  habit  in  children,  it  is  easy  to  re-establish  the  health,  if  we 
can  prevent  the  little  patient's  masturbating  himself,  for  at  this  period  the  resources 
of  Nature  are  great.  It  is  not  so  easy,  however,  to  repair  the  injury  inflicted  on 
nutrition  during  the  development  of  the  body;  nevertheless  the  consequences  dis- 
appear readily,  and  all  the  functions  become  re-established;  not  so,  however,  when 
masturbation  occurs  after  puberty. 


EESULTS    OF    MASTURBATION.  557 

In  the  female  enlargement  and  hypersensitiveness  of  the  clitoris  and 
labia  minora,  with  a  reddened,  lijqDersecreting  condition  of  the  mucous  mem- 
brane, are  usual.  So  sensitive  may  the  parts  become  that  the  most  careful 
examination  may  ^Jroduce  orgasm. 

The  mind  is  usually  disturbed  in  both  sexes,  but  more  from  a  sense  of 
shame  and  a  fear  of  jjossible  results  than  from  physical  cerebral  disturb- 
ance. Naturally  the  frequent  discharge  of  nervous  force  produces  more  or 
less  debility  and  nervous  irritability:    i.e.,  neurasthenia. 

The  assertion  may  be  safely  made  that  every  man  who  has  ever  mas- 
turbated to  any  extent  has  forever  lost,  to  a  greater  or  less  degree,  his 
capacity  for  sexual  enjoyment,  and  the  same  is  true  of  women.  Much,  of 
matrimonial  happiness  is  due  to  this  fact,  and  the  divorce-court  speaks 
volumes  in  evidence  of  it.  Failing  to  secure  the  anticipated  pleasure,  and 
not  recognizing  the  source  of  the  fault,  the  individual  is  apt  to  stray  into 
forbidden  paths  in  quest  of  that  which,  like  the  ignis  fatuus,  ever  eludes 
the  grasp.     Persistent  local  irritation  is  a  factor  in  this. 

The  importance  of  insanity  and  imbecility  in  their  relations  to  mas- 
turbation has  been  greatly  exaggerated,  and  authorities  are  divided  as  to 
the  causal  relation  of  the  vice  to  mental  disease.  Very  often  the  physician 
confounds  the  propter  with  the  post;  indeed,  it  is  probable  that  no  healthy 
boy  was  ever  made  insane  by  masturbation  alone.  Given,  however,  a  feeble 
frame,  unstable  cerebral  equilibrium,  structural  disease  of  the  brain,  faulty 
environment,  or  hereditary  predisposition,  and  masturbation  may  prove  a 
powerful  element  in  the  determination  of  insanity  and  imbecility.  Mas- 
turbation produced  by  actual  brain  disease,  as  in  senile  dementia,  or  asso- 
ciated with  sexual  perversion  does  not  concern  us  here.  Phthisis,  epilepsy, 
cardiac  disease,  neurasthenia,  hypochondria,  nymphomania,  satyriasis,  etc., 
are  the  principal  remaining  disturbances  alleged  to  be  produced  by  mas- 
turbation. The  author  holds  very  much  the  same  position  regarding  them 
as  in  relation  to  insanity,  with  the  exception  of  functional  cardiac  disturb- 
ance, neurasthenia,  and  h3q3ochondria.  These  conditions  may  result  from 
-any  cause  that  produces  a  morbid  impression  upon  the  mind  and  nervous 
system,  and  are,  therefore,  frequent  results  of  masturbation. 

With  the  premise  that  some  peculiarity  of  physical  structure,  hereditary 
or  acquired,  exists  as  a  predisposing  factor,  it  must  be  admitted  that  mas- 
turbation is  an  occasional  cause  of  insanity.  The  intimate  relation  between 
the  functions  of  the  central  nervous  system  and  the  sexual  organs  is  suffi- 
cient to  suggest  the  possibility  of  insanity's  arising  from  abuse  of  the  sexual 
powers,  under  physical  circumstances  favoring  mental  derangement. 

From  a  priori  considerations,  involving  the  immediate  effects  of  sexual 
excitement  and  indulgence  upon  the  brain  and  spinal  cord,  we  might  nat- 
urally expect  insanity  to  be  a  frequent  result  of  masturbation  and  excessive 
venery.  It  is  to  be  remembered,  however,  that  there  is  a  special  provision 
of  nature  for  the  restoration  of  nerve-force  after  sexual  indulgence.     This 


558  ilASTUEBATIOX   AXD    SEXUAL   EXCESS. 

protects  the  majority  of  indiTidnals  "who  abuse  their  sexual  apparatus 
from  immediate  and  serious  results  inyolTing  the  cerebro-spinal  func- 
tions. Even  in  the  young  and  growing  child,  and  in  the  youth  at  the 
period  of  puberty,  the  vital  powers  are  so  active,  and  the  circumstances 
promoting  tissue-building  and  repair  of  nerve-waste  are  so  favorable, 
that  the  nervous  structures  are  protected  for  a  long  time.  Between  the 
sexual  acts  there  is  a  rapid  building  up,  which  prevents  immediately  serious 
results.  ^^Tien  sexual  abuse  is  discontinued,  whether  such  abuse  consists  in 
masturbation  or  overindulgence  in  sexual  intercourse,  recuperation  is  ex- 
traordinary rapid.  No  matter  how  seriously  disturbed  the  functions  of  the 
cerebro-sjoinal  axis  may  appear  to  be  primarily,  the  restoration  of  function 
and  power  usually  speedily  occurs  when  the  cause  of  excitation  and  irri- 
tability has  been  removed,  actual  structural  change  in  the  nervous  system 
being  very  rare  in  these  cases.  When,  on  the  other  hand,  there  exists  a 
condition  of  unstable  nervous  equilibrium  incidental  to  faulty  and  imperfect 
nervous  structure,  whether  due  to  heredity,  congenital  defect,  or  acquired 
disease,  the  conditions  are  entirely  different.  Under  these  circumstances, 
actual  structural  alteration  of  nerve-fibers  and  cells  and  the  vessels  of  the 
brain,  with  coincidental  psychopathic  phenomena,  are  naturally  to  be  ex- 
pected as  occasional  results  of  the  severe  and  repeated  shocks  to  the  suscep- 
tible nervous  system  produced  by  the  sexual  orgasm.  The  immediate  effect 
of  sexual  desire  upon  the  brain — even  in  individuals  considered  perfectly 
sound  from  both  a  physical  and  mental  stand-point — is  sometimes  very 
marked.  In  certain  individuals,  in  whom  the  amorous  propensity  is  very 
pronounced,  the  reason,  will,  and,  indeed,  all  of  the  higher  faculties  of  the 
mind  are  inhibited  for  the  time  being  under  the  influence  of  sexual  passion, 
leaving  the  individual  to  be  swayed  entirely  by  his  animal  impulses.  While 
in  this  condition  of  furor  sexualis  the  most  extravagant  and  unreasonable  acts 
of  sexual  immorality  and  crime  are  often  committed  by  individuals  who,  in 
their  sober  senses,  would  abhor  such  viciousness.  It  is  safe  to  assume  that 
very  few  individuals  of  a  passionate  disposition  can  be  said  to  be  perfectly 
balanced  mentally  when  under  the  influence  of  powerful  sexual  desire.  If, 
then,  the  sexual  passion  is  capable  of  obtunding  the  moral  sensibility, 
reason,  and  judgment  of  individuals  who  are  structurally  sound,  what  is 
to  be  expected  of  persons  of  a  primarily  feeble  intellect  and  faulty  nervous 
structure?  There  seems  to  exist  in  some  cases,  in  which  the  intellect  is 
comparatively  feeble,  a  surprising  degree  of  sexuality.  As  expressed  by 
Deslandes,  "the  generative  sensibility  is  often  augmented  in  proportion  as 
the  intellect  becomes  enfeebled." 

It  is  unfortunate  that  those  who  have  had  most  opportunities  for  the 
study  of  masturbatory  lunatics  have  not  made  a  more  careful  analj'^sis,  not 
only  of  the  relation  of  masturbation  to  the  deplorable  mental  condition  of 
their  patients,  but  of  the  relation  of  hereditary  and  acquired  predisposing 
causes,  both  to  the  acquirement  of  the  habit  and  its  resitlts  upon  the  brain. 


EELATION    OF   MASTUEBATION    TO    INSANITY.  559 

Some  very  eminent  writers  tend  to  exaggerate  the  importance  of  the 
relation  of  masturbation  to  insanity.  Esquirol  has  made  much  of  the  habit 
as  the  primary  cause  of  mental  maladies.    Eitchie  says:— 

As  might  be  expected,  these  cases  chiefly  occur  in  members  of  families  of  strict 
religious  education.  Experience  supports  this  expectation;  and  facts  also  show  that 
those  who  from  this  cause  become  insane  have  generally  been  of  strictly  moral  life, 
and  recognized  as  persons  who  have  paid  much  attention  to  the  forms  of  religion.  It 
is  also  frequently  observed,  especially  in  the  acute  attack  resulting  from  this  cause, 
that  religion  forms  a  noted  subject  of  conversation  or  delusion.^ 

This  opinion,  so  far  as  it  goes,  is  really  a  substantiation  of  what  has 
already  been  said  regarding  the  necessity  of  some  primary  predisposing 
condition  in  the  majority  of  cases  of  so-called  masturbatory  insanity.  It  is 
hardly  conceivable  that  religion  per  se  is  ever  a  cause  of  mental  disease. 
That  prolonged  fasting  and  other  religious  exercises,  in  combination  with 
the  various  emotions  to  which  religious  ceremonies  are  apt  to  give  rise,  may 
produce  mental  disturbance  in  certain  individuals  of  primarily  feeble  nerv- 
ous structure  and  unstable  nervous  equilibrium  is  unquestionable. 

It  can  hardly  be  said  that  the  masturbatory  lunatic  presents  a  char- 
acteristic form  of  psychopathia.  Such  patients,  however,  are  liable  in  some 
instances  to  transitory  maniacal  excitement,  alternating  with  periods  of 
depression  and  melancholic  delusion.  In  many  cases  there  is  a  tendency  to 
monomania  of  a  religious  cast.  In  occasional  cases  the  melancholia  termi- 
nates in  attempts  at  suicide  or  self-mutilation. 

It  is  probable  that  epilepsy  bears  about  the  same  relation  to  masturba- 
tion as  does  insanity,  in  that  a  primary  predisposition  is  necessary  in  order 
that  the  cause  may  be  operative  in  its  production.  That  individuals  sub- 
ject to  epilepsy  are  apt  to  have  an  attack  when  under  the  influence  of  sex- 
ual excitement  is  well  known.  It  is  related  of  the  first  Napoleon — who,  as 
is  well  known,  was  subject  to  epilepsy- — that  he  experienced  a  paroxysm 
every  time  he  attempted  copulation. 

Phthisis,  as  a  result  of  masturbation  and  sexual  excess,  has  been  dwelt 
upon  mainly  by  quacks,  but  to  a  certain  extent  the  subject  has  received  at- 
tention from  reputable  and  scientific  physicians.  The  causal  relation  of 
sexual  abuse  and  excess  to  consumption  has  been  overrated.  Instead  of 
consumption's  being  a  frequent  result  of  masturbation,  it  is  probable  that 
the  peculiar  nervous  organization  of  the  phthisically-disposed  is  very  often 
a  predisposing  cause  of  sexual  excess  and  masturbation.  Satyriasis  and 
nymphomania  are  occasionally  observed  as  phenomena  in  the  clinical  his- 
tory of  phthisis.  A  case  has  already  been  mentioned  of  a  woman  in  the 
last  stages  of  consumption  who  continually  importuned  her  husband  to  have 
intercourse  with  her,  the  sexual  impulse  being  particularly  strong  a  short 
time  before  death.    In  a  general  way,  it  may  be  accepted  that  the  relation 

^  Quoted  by  Aeton. 


560  MASTUEBATION    AND    SEXUAL    EXCESS. 

of  masturbation  and  sexual  excess  to  pulmonary  consumption  is  precisely 
the  same  as  that  of  any  other  condition  involving  nervous  waste  and  vital 
depression.  Anything  that  will  lower  resisting  power  predisposes  to 
phthisis.  The  fact  that  quite  a  proportion  of  consumptive  males  are  mas- 
turbators  is  a  very  weak  argument,  for  the  reason  that  the  majority  of 
males  masturbate  .more  or  less  at  some  period  of  their  lives. ^ 

The  effects  of  masturbation  and  sexual  excess  upon  the  heart  are  very 
similar  to  those  produced  by  mental  excitement,  overstudy,  nervous  shock, 
liquor,  and  the  excessive  use  of  tobacco.  Palpitation  and  breathlessness  are 
the  most  frequent  manifestations  of  sexual  errors.  It  has  been  alleged  that 
cardiac  hypertrophy  and  dilation  may  result  from  overuse  of  the  sexual 
apparatus.  This,  however,  is  open  to  question;  the  capacity  for  experi- 
encing orgasm  probably  becomes  exhausted  long  before  such  results  can 
occur. 

Some  writers,  following  Lallemand,  have  dwelt  much  upon  a  cold, 
clammy  feel  of  the  palms  as  characteristic  of  the  masturbator,  but  this 
sign  is  fallacious.  Its  only  claim  to  accuracy  probably  lies  in  the  fact  that, 
inasmuch  as  most  boys  masturbate,  it  is  safe  to  assume  that  the  boy  with 
the  moist  and  clammy  hand-clasp  is  addicted  to  the  practice  like  his 
fellows.  That  the  assumption  is  apt  to  prove  correct  in  the  majority  of 
cases  is  no  proof  of  the  accuracy  of  the  sign.  It  would  be  as  logical  to  as- 
sume that  a  boy  masturbates  because,  forsooth,  he  is  a  boy;  a  very  safe  rule, 
by  the  way. 

The  peculiar  mentality  of  some  adult  masturbators  is  aptly  illustrated 
by  the  confessions  of  Eosseau.  This  unfortunate  individual,  although  one 
of  the  most  renowned  literati  and  philosophers  of  his  day,  not  only  tacitly 
confesses  in  his  writings  that  he  habitually  practiced  masturbation,  but  de- 
lineates in  a  most  impressive  and  striking  manner  the  influences  that  con- 
tributed to  the  excitation  of  his  sexual  passions,  and  shows  in  an  all-too- 
vivid  manner  the  attractiveness  that  the  imagination  of  youth  finds  in  the 
disgusting  habit.     In  the  words  of  an  eminent  writer  upon  the  subject: — 

Rousseau  seemed  to  be  utterly  unaware  that,  the  miserable  mental  and  bodily 
condition,  which  he  goes  on  to  describe  and  to  deplore,  was  in  any  way  the  natural 
consequence  of  the  habit.  This,  perhaps,  is  not  to  be  wondered  at,  since  the  very 
medical  men  he  consulted  did  not  attribute  his  maladies  to  the  real  cause.  Modern  ex- 
perience, however,  and  the  confessions  of  recent  patients  who  have  sinned  and  suffered 
— as  Rousseau  did — give  only  too  clear  an  explanation  of  his  ailments.- 

In  the  case  of  Rousseau  the  habit  of  masturbation  was  undoubtedly  due 
primarily  to  sexual  precocity.  His  description  of  his  mental  condition  is 
most  masterly. 


^  That  sexual  excess  is  often  due  to  consumption  is  questionable.     As  a  rule, 
phthisis,  like  aS  debilitating  diseases,  lessens  both  sexual  desire  and  power. 
^  Acton,  op.  cit. 


MASTURBATION    AND    SEXUAL    EXCESS.  561 

The  intellectual  brilliancy  displayed  by  this  celebrated  victim  of  mas- 
turbation is  certainly  paradoxic,  if  the  elaborate  descriptions  given  by  some 
writers  of  the  mental  hebetude  and  stupidity  resulting  from  the  vice  are 
to  be  believed.  The  explanation,  however,  probably  lies  in  the  fact  that 
Eousseau,  being  a  man  of  extraordinary  intellectual  power,  was  not  afEected 
as  the  average  individual  would  be.  The  mental  vagaries,  inaptitude  for 
mental  concentration,  sluggishness  of  thought,  shrinking  from  society,  hy- 
jDersensitiveness,  disturbed  emotional  equilibrium,  and  morbid  introspection 
described  by  him  are  matters  of  every-day  experience  to  individuals  who 
have  indulged  in  masturbation  to  any  great  extent.  These  are,  moreover, 
phenomena  which,  if  the  truth  were  known,  have  been  experienced  even 
by  those  who  have  succeeded  in  breaking  off  the  habit,  and  have  apparently 
suffered  no  permanent  evil  results  from  it. 

SEXUAL   EXCESS. 

In  a  general  way,  sexual  excess  bears  the  same  relation  to  physical  and 
mental  disturbances  as  masturbation.  The  results  differ  chiefly  in  degree, 
and  physical-  impairment  from  sexual  excess  is  more  frequent  than  is  gen- 
erally supposed.  Earely,  indeed,  is  our  attention  called  to  such  serious  con- 
sequences as  may  result  from  masturbation,  but  there  are  numerous  reasons 
that  satisfactorily  explain  this.  The  general  belief  is  that  the  extent  of 
sexual  indulgence  is  to  be  limited  only  by  physical  capacity,  as  it  is  unlike 
masturbation  in  being  harmless  under  all  circumstances.  The  author  vent- 
ures to  assert,  however,  that  sexual  excess  is  the  most  prolific  cause  of  that 
most  civilized  and  fashionable  of  all  hydraheaded  diseases,  neurasthenia. 

Excessive  sexual  indulgence  is,  of  course,  relatively  infrequent;  oppor- 
tunities are  not  so  favorable  and  frequent  as  for  masturbation.  The  habit 
of  sexual  excess  is,  to  a  certain  extent,  self-regulating,  because  of  the  fact 
that  exhaustion  of  desire,  and  perhaps  power,  sometimes  occurs  before 
serious  physical  injury  has  been  done,  and  the  individual  must  stop  for  the 
time  being.  The  age  at  which  sexual  excess  is  apt  to  occur  is  generally  far 
enough  advanced  to  escape  the  marked  depression  produced  by  masturba- 
tion upon  the  susceptible  youth.  Continued  excess  will,  however,  produce 
effects  similar  to  those  of  masturbation. 

The  reciprocal  "magnetism"  experienced  during  normal  intercourse  un- 
doubtedly protects  the  individual  to  a  certain  extent,  and  several  patients 
have  stated  that  intercourse  with  some  females  is  extremely  exhausting 
to  them,  while  Avith  others  they  are  not  debilitated  by  much  more  liberal 
indulgence.  That  this  magnetism,  however,  protects  the  reckless  roue  in 
pursuit  of  variety  is  questionable. 

The  extent  to  which  cohabitation  may  be  indulged  in  with  impunity 
necessarily  varies  with  the  individual,  but,  on  the  average,  it  may  be  said 
that  there  are  few  who  are  not  injured  by  indulgence  oftener  than  twice  or 
thrice  weekly.    One  of  the  author^s  patients  expressed  a  view  that  was  hardly 


562  ilASTUKBATIOX    AXD    SEXUAL    EXCESS. 

in  accordance  with  this,  in  the  statement  that  he  was  "'now  very  moderate'^ 
and  conld  "get  along  yery  well  with  a  single  nightly  indulgence."  Another 
subject  claims  to  have  achieved  a  record  of  thirty-two  separate  and  perfect 
acts  of  copulation,  with  orgasm,  within  thirty-six  hours,  and  does  not  con- 
sider the  exploit  remarkable — which  cannot  be  said  of  his  story. 

Much  of  the  nervous  derangement  met  with  in  both  men  and  women 
is  probably  due  to  excessive  sexual  indulgence,  and  it  is  certain  that  many 
local  diseases  of  women  are  either  produced  or  enhanced  by  sexual  excess. 
Very  little  consideration  is  shown  by  the  average  man  toward  his  wife;  in- 
deed, her  welfare  is  usually  a  secondary  consideration  in  sexual  matters. 
Voluntary  sexual  excess  on  the  part  of  women  is  rare,  and,  where  they  are 
especially  importunate,  there  is  usually  some  physical  defect  to  account  for 
it.  With  men  sexual  excess  is  voluntary,  in  and  out  of  matrimony.  It  is 
the  misfortune  of  many  men  to  believe  that  their  existence  revolves  around 
the  penis  and  testicles;  indeed,  a  large  proportion  of  masculine  humanity 
is  imbued  with  the  fatuous  idea  that  man's  principal  mission  in  life  is  pan- 
dering to  his  own  animal  appetites.  In  thus  worshiping,  so  to  speak,  his 
virile  members,  man  reverts  back  to  a  period  of  the  world's  history  so 
ancient  as  to  make  the  situation  as  ludicrous  as  it  is  humiliating.  It  is  the 
author's  belief  that  if  the  sexual  monomaniacs  were  removed  from  society 
its  ranks  would  be  sadly  depleted. 

The  importance  of  the  relation  of  sexual  excess  and  masturbation  to 
the  welfare  of  the  human  race  is  obvious.  We  have  but  to  review  our 
ancient  history  a  little  to  observe  the  deterioration  of  races  resulting  from 
unbridled  licentiousness.  It  would  be  well  for  both  men  and  women  to 
understand  that  if  they  desire  to  perpetuate  their  families  with  good  healthy 
stock  they  must  be  moderate  in  sexual  indulgence.  Every  stock-breeder 
understands  this  principle,  and  we  may  as  well  learn  to  apply  it  to  the 
human  species.  Marriage  at  a  premature  age  bears  the  same  relation  to  the 
quality  of  the  progeny  as  does  sexual  excess  in  more  mature  life.  It  has 
been  found  that  breeding  very  young  animals  is  unprofitable,  for  the  reason 
that  the  progeny  are  poorly  developed  and  weak.  In  a  general  way  it  may 
be  said  that  in  the  case  of  the  human  subject  the  progeny  of  individuals  who 
marry  very  young  are  almost  invariably  unfit  for  the  struggle  for  existence. 
The  result  is,  in  many  instances,  very  similar  to  that  of  consanguinity. 

Experiments  by  Goddard  years  ago  showed  that  in  animals  frequent 
copulation  impairs  the  quality  and  quantity  of  the  semen.  Examination  of 
the  sperm  ejaculated  by  stallions  at  different  acts  of  copulation  during  the 
same  day  showed  that  the  spermatic  fluid,  although  dense,  opalescent,  and 
of  a  yellowish  or  amber  color  at  the  first  cover,  became  thinner  and  clearer; 
so  that  after  about  the  fourth  act  of  copulation  it  was  almost  like  water,  the 
spermatozoids  being  very  few  in  number.  The  experimenter  concluded  that 
the  spermatic  fluid  ejaculated  at  the  flrst  act  of  copulation  in  the  morning 
would  be  quite  certain  to  fecundate,  while  that  of  later  acts  would  fre- 


TEEATMENT    OF    MASTUKBATION    AND    SEXUAL    EXCESS.  563 

quently  fail.  It  is  therefore  better  for  a  stallion  to  be  allowed  to  cover  only 
one  mare  per  day,  the  result  being  much  better  than  where  the  animal  is 
obliged  to  cover  four  or  five.^ 

Individuals  who  indulge  excessively  in  coitus  notice  that  the  orgasm 
after  numerous  acts  of  intercourse  is  attended  by  the  expulsion  of  little  or 
no  semen.  The  fluid  that  attends  ejaculation  after  repeated  orgasm  is  com- 
posed mainly  of  secretion  from  the  prostate,  Cowper's  glands,  and  urethral 
follicles.  This  shows  conclusively  that  the  individual  who  copulates  most 
is  apt  to  create  the  least,  and  vice  versa. 

The  most  frequent  results  of  sexual  excess  met  with  in  practice  are 
premature  failure  of  sexual  power,  impairment  of  vigor,  premature  ejacula- 
tion, partial  and  complete  impotence.  These  conditions  will  receive  atten- 
tion later  on.  Sexual  perversion  in  its  various  forms  is  one  of  the  rarer  re- 
sults of  masturbation  and  sexual  excess. 

UNPHYSIOLOGIC    COITUS. 

Any  method  of  producing  the  orgasm  by  contact  of  the  sexes  save  the 
normal  one  is  unphysiologic,  and  therefore  injurious.  Onanism,  or  prema- 
ture withdrawal  for  the  purpose  of  avoiding  pregnancy,  is  a  common  prac- 
tice, and  one  against  which  the  laity  should  be  warned.  Its  injurious  ef- 
fects are,  in  general,  similar  to  those  of  masturbation  and  sexual  excess. 
Coitus  interruptus  is  often  injurious. 

TREATMENT. 

The  management  of  masturbation  and  sexual  excess  is  largely  of  a 
moral  character,  and  chiefly  prophylactic  rather  than  curative. 

The  first  step  in  the  cure  or  prevention  of  the  vice  of  masturbation 
and,  incidentally,  of  sexual  excess,  is  to  improve  the  moral  tone  and 
strengthen  the  intellectual  power  of  the  patient.  The  more  perfect  the 
mental  discipline,  the  easier  it  will  be  to  improve  the  morale  of  the  indi- 
vidual. One  of  the  first  steps  should  be  the  interdiction  of  all  literatu.re, 
classic  or  otherwise,  that  tends  to  foster  sexual  impulses.  Any  work  that 
treats  of  sexual  matters  in  a  manner  suggestive  of  condonation  of  indul- 
gence is  injurious,  no  matter  how  gilded  the  phraseology  may  be.  Strange 
as  it  may  seem,  there  is  a  certain  amount  of  innate  depravity  in  the  human 
mind  which  impels  growing  lads,  and  sometimes  girls,  to  seek  for  pruriency 
in  everything  they  read.  Even  the  Bible  is  not  unimpeachable  regarding 
its  effects  upon  the  young;  indeed,  there  are  few  books  from  which  a  child 
can  obtain  more  pernicious  ideas  of  sexual  matters  than  from  the  Old  Testa- 
ment. Oftentimes  a  natural  and  pardonable  curiosity  impels  a  child  to 
seek  for  information  upon  a  subject  toward  which  he  instinctively  turns, 
but  in  regard  to  which  he  has  always  been  kept  in  ignorance. 

There  is  one  point  in  sexual  physiology  that  should  always  be  impressed 

^  "Traite  de  Physiologie,"  par  Longet. 


564  MASXrEBATIOX    AXD    SEXUAL    EXCESS. 

iipon  our  patients.  The  impression  prevails  among  young  men  that  ex- 
ercise of  the  sexual  function  is  an  absolute  physical  necessity,  irrespective 
of  the  method  of  its  accomplishment.  Indeed,  it  is  probable  that  some  phy- 
sicians, Tvho  certainly  ought  to  know  better,  foster  this  idea  by  ill-weighed 
and  injudicious  counsel.  This  idea  is  most  ijernicious  in  its  effects  and  it 
becomes  our  duty  to  correct  it.  Although  no  adult  man  or  woman  under 
existing  social  conditions  is  physiologically  well-balanced  in  a  state  of 
celibacy,  one  may  be  perfectly  healthy  and  physically  vigorous  while  lead- 
ing a  life  of  absolute  continence,  if  the  mind  be  properly  disciplined  and 
the  body  made  completely  subservient  to  the  will.  The  excuse  of  physical 
necessity  is  too  often  a  subterfuge  to  justify  fornication  and  even  masturba- 
tion. That  such  an  excuse  should  ever  be  offered  is  striking  testimony  re- 
garding the  prevalent  ignorance  of  sexual  physiology.  A  better  education 
in  the  ethic  and  physiologic  aspects  of  the  sexual  function  is  a  crying  neces- 
sity. 

The  patient  should  be  impressed  with  the  idea  that  the  sexual  appa- 
ratus is  less  than  a  secondary  consideration  in  the  physical  life  of  the  in- 
dividual; indeed,  the  average  man  would  be  better  off'  without  it  so  far  as  his 
mere  physical  welfare  is  concerned.  It  is  unnecessary  to  existence,  and  its 
functions  may  be  held  in  abeyance  for  very  long  periods,  even  for  life,  with- 
out necessarily  producing  physical  injury.  "When  thus  held  in  abeyance  the 
generative  function  may  be  called  into  action  at  any  time  and  present  no 
evidences  of  deterioration  from  the  compulsory  rest — assuming  that  the 
physical  has  been  held  under  the  control  of  the  moral  nature.  If  the  mind 
be  disturbed  Ijv  sexuahty,  as  it  is  apt  to  be  in  our  present  state  of  society, 
enforced  sexual  rest  is  often  productive  of  evil  effects.  AYlien.  in  the  strug- 
gle between  the  moral  and  physical  natures,  the  will  is  triumphant,  the  re- 
sult is  never  detrimental. 

The  old  maxim  that  ''idleness  is  the  mother  of  mischief^'  is  especially 
applicable  to  the  sexually  depraved,  which  naturally  leads  to  the  corollary 
that  proper  mental  and  physical  training  and  exercise  are  a  potent  antidote 
to  sexuality  of  both  thought  and  action.  The  individual  who  exercises  both 
mind  and  body  to  the  extent  of  reasonable  fatigue  has  little  desire  for  sex- 
ual indulgence.  There  is  no  better  anaphrodisiac  than  an  hour  in  the  gym- 
nasium, followed  by  a  cold  shower  and  a  vigorous  rub.  The  lad  who  takes 
pride  in  his  physique  and  is  attracted  to  athletic  sports  is  seldom  addicted 
to  masturbation  a?  compared  with  his  fellows.  The  practice  of  athletics 
necessitates  sexual  abstinence  or  moderation,  as  is  well  known  to  trainers; 
indeed,  every  athlete  knows  that  after  a  few  weeks'  training  the  desire  for 
sexual  indulgence  is,  in  a  measure,  lost. 

Physical  exercise,  in  addition  to  diverting  the  superfluous  nervous 
energy  from  the  sexual  organs,  is  also  beneficial  by  lessening  the  activity  of 
secretion  of  semen,  and,  inasmuch  as  distension  of  the  tubuli  seminiferi  and 
seminal  vesicles  by  semen  acts  reflexly  in  producing  sexual  desire,  anything 


TKEATMENT    OP    lIASTURBATIOjSr    AXD    SEXUAL    EXCESS.  565 

that  inhibits  the  secretion  is  necessarily  beneficial.  Muscular  exercise  that 
involves  a  certain  amount  of  attention  and  mental  application,  such  as  box- 
ing, fencing,  cricket,  hand-ball,  etc.,  are  particularly  beneficial,  as  tending 
to  divert  the  mind  from  sexual  matters.  The  effect  of  the  mind  upon  se- 
cretion is  illustrated  not  only  by  the  effect  of  mental  emotion  upon  the 
sexual  organs,  but  upon  the  lacteal,  gastric,  and  salivary  secretions.  It  is 
possible  for  an  individual  to  indulge  immoderately  in  physical  exercise  and 
yet  have  the  mind  constantly  occupied  by  sexual  affairs.  The  exercises  men- 
tioned are  therefore  more  apt  to  secure  the  desired  result  than  those  that 
merely  involve  physical  labor. 

With  reference  to  continence  in  youth,  Acton  says: — 

The  argument  in  favor  of  the  great  mental,  moral,  and  physical  advantage  of 
early  continence  does  not  want  for  high  secular  authority  and  countenance,  as  the 
recollection  of  the  least-learned  reader  will  suggest  in  a  moment.  Let  us  be  content 
here  with  the  wise  Greek,  who,  to  the  question  when  men  should  love,  answered: 
"A  young  man,  not  yet;  an  old  man,  not  at  all";  and  with  the  still- wiser  English- 
man, who  thus  writes:  "You  may  observe  that  among  all  the  great  and  worthy 
persons  (whereof  the  memory  remaineth,  either  ancient  or  recent)  there  is  not  one 
that  hath  been  transported  to  the  mad  degree  of  love — which  shows  that  great  spirits 
and  great  business  do  keep  out  this  weak  passion.  .  .  .  By  how  much  the  more 
ought  men  to  beware  of  this  passion,  which  loseth  not  only  other  things,  but  itself. 
As  for  the  other  losses,  the  poet's  relation  doth  well  figure  amorous  affection,  for  he 
quitteth  both  riches  and  wisdom.  .  .  .  They  do  rest,  who,  if  they  cannot  but 
admit  love,  yet  make  it  keep  quarter." 

The  social  habits  of  the  young  require  close  supervision.  Evil  asso- 
ciates are  easily  found  in  any  community,  however  respectable.  It  is  not 
unusual  to  observe  a  cluster  of  boys  admiringly  listening  to  the  lewd  tales 
of  some  stable-boy  or  man-of-all-work,  and  the  instruction  in  vice  received 
at  the  hands  of  his  elders  is  most  pernicious  in  its  effects  upon  a  lad  whose 
highest  ambition  is  to  be  mannish — and  he  is  quite  apt  to  confound  the 
depravity  of  his  teacher  with  manliness. 

Late  hours,  the  dance,  liquor,  tobacco,  high  living,  and  the  society  of 
females  of  questionable  virtue  and  free  manners  foster  sexual  excitability 
and  must  be  avoided.  Suggestive  and  immoral  plays  have  much  to  do  with 
the  vitiated  sexual  tone  of  our  social  system  and  should  be  interdicted. 
When  the  general  health  is  impaired  tonic  treatment  should  be  instituted.  It 
is  often  the  case  that  the  morale  of  the  patient  does  not  appreciably  improve 
until  his  general  physical  condition  has  changed  for  the  better. 

The  importance  of  careful  attention  to  dietetic  regimen  in  controlling 
the  tendency  to  masturbation  and  sexual  excess  can  scarcely  be  overrated. 
The  relation  of  a  stimulating  and  highly  nutritious  diet  to  sexual  desire 
and  capacity  was  well  understood  by  the  ancients.  The  old  maxim — '^Sine 
Bacclio  et  Cerere  friget  Venus'' — is  as  pertinent  as  it  is  classic.  In  the  lives 
of  many  individuals  Bacchus  and  Venus  go  hand  in  hand  as  dominating 
powers.     With  some  persons  excessive  sexual  desire  is  directly  dependent 


566  MASTURBATION   AND    SEXUAL    EXCESS. 

upon  high  living.  G-outy  conditions  of  the  blood  incidental  to  the  latter 
are  especially  apt  to  be  associated  with  irritation  of  the  genito-urinary  tract, 
and  particularly  of  the  nerves  of  the  sexual  sensibility.  If  one  would  re- 
main continent  he  must  not  only  abjure  all  mental  sources  of  sexual  excite- 
ment, but  he  must  also  abstain  from  stimulants,  tobacco,  highly-seasoned 
food — in  short,  all  articles  of  diet  that  tend  to  induce  nervous  irritability.  It 
is  probable  that  a  strictly  vegetarian  regimen  is  the  best  that  can  be  advised 
for  an  individual  who  desires  to  remain  continent  both  in  mind  and  body. 
With  our  present  pernicious  social  customs  the  unaided  efforts  of  the  will 
are  not  always  successful  in  conquering  the  lusts  of  the  flesh. 

When  local  diseases  exist,  whether  the  subject  be  male  or  female,  their 
cure  is  essential,  for,  so  long  as  there  exists  any  source  of  sexual  irritation, 
moral  persuasion  will  be  of  little  avail.  Circumcision  is  a  valuable  measure, 
as  it  relieves  existing  phimosis  and,  by  uncovering  the  gians  finally  results 
in  a  loss  of  sensibility  of  that  structure  to  a  certain  degree,  and  makes  the 
act  of  masturbation  less  attractive.  In  extreme  cases  in  the  female  amputa- 
tion of  the  clitoris  has  been  known  to  cure;  this,  hoAvever,  is  an  operation 
to  be  very  cautiously  advised.  Baker  Brown,  of  London,  the  originator  of 
the  operation,  performed  it  for  all  sorts  of  nervous  troubles  and  received 
severe  censure  for  his  pains;  indeed,  he  was  well-nigh  ostracized  by  his  pro- 
fessional brethren — with  more  sentiment  than  justice  upon  their  part. 

The  bromids,  gelsemium,  camphor,  hyoscyamus,  and  other  drugs  of  the 
anaphrodisiac  class  are  useful  in  some  cases.  They  will  serve  to  lessen  sex- 
ual desire  and  thus  prove  beneficial  where  the  patient  really  wishes  to  break 
off  the  habit.  Cold  bathing  is  an  excellent  adjuvant,  cold  sitz-baths  being 
especially  beneficial.  The  passage  of  the  cold  steel  sound  has  often  an  ex- 
cellent tonic  as  well  as  moral  effect.  The  psychrophor  sometimes  acts  well. 
Deep  instillations  of  silver  nitrate  are  often  very  useful. 

Children  who  are  mentally  defective  should  be  carefully  watched,  for 
once  the  habit  is  commenced  a  cure  is  almost  impossible.  The  masturbatory 
lunatic  is  rarely  cured  of  his  masturbation.  The  penis  has  been  blistered 
from  glans  to  root,  in  such  cases,  without  interfering  with  the  habit.  The 
straight-jacket  might  perhaps  be  of  service  temporarily,  but  immediately 
he  is  liberated  the  poor  unfortunate  invariably  begins  his  vicious  practices 
again.  In  obstinate  cases,  which  means  the  majority,  the  author  unhesi- 
tatingly advocates  castration.  Vasectomy  or  ligation  of  the  vasa  deferen- 
tia  may,  however,  be  tried  first. 

The  prognosis  in  the  majority  of  victims  of  masturbation  is  good,  but 
occasionally  all  means  fail  and  the  patient  becomes  a  mental  and  physical 
wreck.  The  average  boy  or  girl  discovers  the  perniciousness  of  the  practice 
— thanks  to  quack  literature,  as  a  rule — ^before  arriving  at  adult  age,  and 
stops  it,  with  little  apparent  physical  disturbance  resulting  from  the  habit 
later  on. 

Marrias:e  as  a  remedv  for  masturbation  is  not  to  be  thought  of  unless 


TREATMENT    OF   MASTURBATION    AND    SEXUAL    EXCESS.  567 

the  subject  is  perfectly  sound,  mentally  and  physically — or  at  least  prac- 
tically so — and  of  suitable  age.  Under  any  circumstances  the  physician 
should  give  the  matter  most  serious  consideration  before  assuming  the  re- 
sponsibility of  advising  matrimony.  There  is  a  wider  latitude  in  the  case 
■of  women  than  men  in  this  respect,  as  a  woman  is  seldom  impotent. 

In  a  general  way  the  vices  of  sexual  excess  and  unphysiologic  coitus 
require  the  same  management  as  masturbation.  Fortunately  the  patients 
who  indulge  in  venery  to  excess  are  older  and  possessed  of  more  powerful 
wills  than  the  subjects  of  masturbation  and  are  more  easily  influenced  by 
argument,  especially  if  their  selfishness  be  appealed  to. 


CHAPTEK  XXV. 

Impotence  and  Stekility. 

Geneeal  Considerations. — Through  certain  organic  or  functional 
disturbances  of  the  sexual  organs  the  procreative  function  may  fail  of  its 
object.  To  the  sexual  perturbations  that  are  responsible  for  inability  to 
propagate  the  species  the  terms  impotence  and  sterility  are  applied.  These 
conditions  may  be  found  in  both  male  and  female. 

Impotence  implies  inability  to  consummate  the  sexual  act.  This  in- 
ability may  be  due  to  organic  or  psychic  causes,  or,  as  it  is  usually  ex- 
pressed, may  be  real  or  imaginary  in  either  sex.  Irrespective  of  the  under- 
lying cause,  the  material  result  so  far  as  copulation  is  concerned  is  of  a 
purely  mechanic  nature.  The  male  fails  to  penetrate  the  vagina  of  the 
female  because  of  failure,  imperfection,  or  transitory  nature  of  erection,  or 
penile  deformities — congenital  or  acquired — that  make  intromission  impos- 
sible. The  condition  is  rare  in  the  female,  for  the  reason  that,  so  long  as 
she  presents  a  more  or  less  suitable  receptacle  for  the  male  organ,  she  does 
not  usually  consider  herself  impotent.  Impotency  in  the  female  usually 
implies  either  some  deformity  or  disease  that  produces  atresia  of  the  vagina 
or  some  local  inflammatory  affection — acute  or  chronic — that  gives  rise  tO' 
vaginismus:  i.e.,  pain  and  spasm  during  attempts  at  copulation.  In  neu- 
rotic or  hysteric  subjects  this  condition  may  occur  independently  of  local 
inflammation  or  atresia. 

Sterility  practically  implies  incapacity  for  fecundation;  copulation  and 
even  orgasm  may  be  perfect,  yet  fecundation  cannot  occur  because  of  or- 
ganic defect  in  one  or  both  parties  to  the  sexual  act.  These  defects  are 
several,  and,  broadly  speaking,  are  of  two  kinds:  (a)  mechanic  and  (&) 
nutritive.  In  the  first  category  are  (1)  conditions  in  which,  although  copu- 
lation is  normal,  and  both  ovule  and  sperm-cell  are  healthy,  certain  local 
conditions  prevent  them  from  meeting  at  the  proper  time;  (2)  the  germ- 
cell  and  sperm-cell  having  met,  their  blending  is  mechanically  prevented; 
or  (3)  the  ovule  having  been  fecundated,  certain  local  conditions  prevent 
the  development  of  the  ovum. 

In  the  second  category  are  various  more  or  less  obscure  conditions  that 
affect  the  vitality  of  the  ovule  and  the  vitality,  number,  and  activity  of  the 
spermatozoa.  Independently  of  constitutional  weakness  of  either  ovule  or 
spermatozoon,  or  both,  there  is  probably  a  mysterious  lack  of  affinity  be- 
tween them  in  some  cases  that  either  prevents  them  from  blending  or,  if 
blending  occurs,  makes  the  union  unproductive.  Whether  certain  viti- 
.  (568) 


IMPOTENCE    AND    STEEILITT.  569 

ated  conditions  of  ovule  or  spermatozoa  may  make  the  one  deadly  to  the 
,other  is  at  least  open  to  speculation. 

A  moment's  reflection  will  show  that  both  male  and  female  may  be 
theoretically  fertile,  although  practically  sterile.  It  may  also  be  seen  that, 
although  sterile  with  one  person  of  the  opposite  sex,  either  male  or  female 
may  be  fertile  with  others. 

Sterility  and  impotence  may  or  may  not  be  combined.  Thus,  as  a  con- 
sequence of  removal  of  the  testes  the  male  may  be  entirely  shorn  of  sexual 
desire,  and  is  necessarily  at  the  same  time  made  incapable  of  producing  the 
germinal  material  necessary  for  fecundating  the  ovule.  On  the  other  hand, 
the  testes  may  be  removed  in  some  cases,  and  yet  for  a  greater  or  less  length 
of  time  the  potency  of  the  individual  remains  impaired.  Stallions  that  are 
gelded  late  are  apt  to  retain  their  sexual  desire  and  power;  if,  however, 
castration  be  performed  when  they  are  young,  they  are  rendered  both  im- 
potent and  sterile.  It  is  nothing  unusual  for  owners  of  stock  to  keep  on 
hand  a  horse  that  has  been  gelded  late  in  life,  for  the  purpose  of  gratifying 
the  mares  during  the  period  of  horsing.  In  horses  of  this  kind  emissions 
occur  of  a  character  somewhat  resembling  normal  semen,  although  sperma- 
tozoa are  necessarily  absent.  The  secretion  emitted  under  such  circum- 
stances is  furnished  by  the  mucous  glands  of  the  urethra,  the  prostatic 
follicles,  and  Cowpers  glands.  The  possibility  of  retention  of  the  power  of 
copulation  after  castration  is  so  well  recognized  in  the  harems  of  the  East 
that  eunuchs  from  whom  both  testes  and  penis  have  been  removed  bring 
a  much  higher  price  in  the  market  than  those  who  have  been  merely  cas- 
trated. Individuals  who  are  absolutely  incapable  of  emitting  true  semen 
may  be  perfectly  potent.  Such  cases  are  an  illustration  of  potency  com- 
bined with  sterility. 

Individuals  in  whom  the  testes  are  intact,  the  penis  having  been  re- 
moved, are  necessarily  impotent,  although  under  favorable  circumstances 
they  could  hardly  be  said  to  be  sterile.  If  it  were  practicable  to  bring  the 
semen  of  such  individuals  in  contact  with  the  healthy  ovule,  fecundation 
would  be  as  likely  to  occur  as  in  individuals  possessing  perfect  virile  power. 
The  same  holds  true  of  men  whose  epididymes,  vasa  deferentia,  or  ejacula- 
tory  ducts  have  been  occluded  by  injury  or  disease.  In  time  the  testes 
may  fail  to  elaborate  fertile  semen,  but  at  first  it  certainly  is  formed.  In- 
dividuals who  from  various  causes  are  unable  to  secure  or  maintain  an 
erection,  may  nevertheless  be  capable  of  impregnating  the  female,  for  such 
persons  are  likely  to  have  emissions,  and  the  ejaculated  fluid  may  be  capable 
of  fecundating  the  ovule.  It  is  not  even  necessary  that  the  semen  thus 
ejaculated  should  be  thrown  into  the  vagina,  as  has  been  shown  in  instances 
in  which  contact  and  emissions  without  penetration  have  been  permitted  by 
the  female,  with  resulting  pregnancy.  It  appears  to  be  possible  for  preg- 
nancy to  occur  when  the  semen  is  deposited  only  upon  the  external  female 
genitals,  although  the  recorded  evidence  is  somewhat  dubious. 


570  •        steeility  in  the  male. 

Sterility  in  the  Male. 

Sterility  in  the  male  has  been  sadly  neglected  by  the  profession.  When  • 
consulted  with  reference  to  nnfruitfulness  in  married  life,  the  medical  man, 
as  a  matter  of  routine,  usually  attributes  the  difficulty  to  some  inherent 
incapacity  or  acquired  morbid  condition  of  the  female.  It  is  probable  that 
much  of  the  effort  that  is  directed  to  the  cure  of  sterility  in  women  is  mis- 
applied, the  husband  and  not  the  wife  being  at  fault.  If  the  direct  and 
remote  results  of  gonorrheal  infection  in  both  male  and  female  be  given 
due  consideration,  the  responsibility  of  the  sterner  sex  in  the  matter  of 
sterility  will  at  once  be  seen  to  be  considerable.  It  has  been  stated  by 
eminent  gynecologists — and  with  reason — that  at  least  one-sixth  of  the  cases 
of  sterility  that  are  brought  to  the  attention  of  the  physician,  are  due,  not 
to  difficulties  in  the  female,  but  to  morbid  conditions  in  the  male. 

Etiology. — Sterility  in  the  male  is  due  to :  1.  Some  morbid  condition 
that  perverts  the  vitality  of  the  seminal  fluid  and  renders  it  incapable  of 
fecundating  the  ovum.  2.  Conditions  obstructing  the  escape  of  the  semen 
from  the  ejaculatory  ducts.  3.  Conditions  preventing  the  proper  deposition 
of  the  semen  in  the  vagina.  4.  Defective  development  of  the  testes  is  apt 
to  give  rise  to  sterility  on  account  of  the  functional  inactivity  of  the  im- 
perfect organs.     5.  Cryptorchidism. 

According  to  Kehrer,  the  cause  of  childless  marriages  is  to  be  sought 
much  oftener  on  the  side  of  the  man  than  has  heretofore  been  the  custom. 
This  statement  is  based  upon  investigations  of  the  semen.  Kehrer  inves- 
tigated ninety-six  cases: — 

In  3.12  per  cent,  there  existed  inability  to  copulate;  in  all  such  cases  there  had 
been  preceding  masturbation.^  The  men  suffered  from  frequent  pollutions,  or  the 
ejaculations  were  premature  and  the  penis  could  not  be  inserted  into  the  vagina.  In 
these  cases  Kehrer  claims,  impregnation  may  result,  if  before  the  attempt  at  coitus  a 
speculum  be  introduced  into  the  vagina.  In  several  cases  conception  was  obtained  by 
this  maneuver.  In  31.21  per  cent,  azoospermia — absence  of  spermatozoa — existed. 
In  most  of  these  cases  gonorrhea,  with  unilateral  or  bilateral  orchitis,  had  preceded. 
The  author  lays  particular  stress  upon  occlusion  of  the  ejaculatory  ducts  through 
gonorrheal  prostatitis.  But  azoospermia  was  also  found  where  no  disease  of  the  sexual 
organs  had  occurred,  and  where  nothing  abnormal  in  the  genital  organs  could  be 
demonstrated.  Oligospermia- — deficient  quantity  of  semen — was  demonstrated  in  11.45 
per  cent.  Several  times  masturbation  was  confessed,  or  else  gonorrhea  with  orchitis, 
or  syphilis,  had  preceded.  But,  in  addition,  Kehrer  thinks  that  the  diseases  of  the 
female  sexual  apparatus  that  may  cause  sterility  are  considered  too  lightly. 

Utero-vaginal  catarrh  under  certain  circumstances  leads  to  sterility,  and 
Kehrer  also  thinks  that  bacteria  may  exert  a  destructive  influence  upon  the 
ovules.    It  is  a  question  whether  these  bacteria  produce  inflammation  of  the 


^  Considering  the  prevalence  of  masturbation,  this  observation  is  of  no  special 
value. 


ETIOLOGY    OF    STEEILITT    IN    THE    MALE.  571 

mucous  membrane  or  only  find  in  the  latter  suitable  conditions  for  further 
develojDment.  Noeggerath  found  eight  sterile  marriages  in  a  series  of  four- 
teen to  be  the  fault  of  the  male.  Gross,  in  a  table  comprising  one  hundred 
and  ninetj^-two  cases,  shows  that  the  male  was  deficient  in  one  out  of  every 
six. 

Sterility  in  the  male  may  be  due  to  any  of  the  following  conditions: — 

(a)  Non-secretion  of  semen — aspermia. 

(b)  The  semen  may  not  contain  spermatozoa — azoospermia. 

(c)  The  spermatozoa  may  be  few  in  number,  motionless,  or  their  move- 
ments ephemeral- — oligospermia. 

(d)  Obstruction  to  the  passage  of  active  semen  to  the  deep  urethra  and 
seminal  vesicles. 

(e)  Obstruction  to  its  escape  from  the  meatus — as  in  stricture. 

(/)  Escape  of  the  semen  at  some  point  between  the  deep  urethra  and 
meatus,  thus  preventing  its  proper  deposition  in  the  vagina — as  seen  in 
hypospadias  and  extensive  urethral  fistula. 

Cryptorchids,  in  whom  the  testes  are  not  only  retained,  but  are  also  in 
an  embryonal  and  imperfectly-developed  condition,  are  usually,  if  not  in- 
variabl}^,  sterile;  this  does  not  apply  to  monorchids.  Cryptorchids  are  often 
potent  to  a  high  degree.  A  cryptorchid  gonorrheic  under  the  author's  care 
is  extremely  vigorous  sexually.  Individuals  from  whom  both  testicles  have 
been  removed  are  necessarily  sterile.  When  both  organs  have  sustained 
serious  injuries,  sterility  may  result,  either  from  destruction  of  the  secreting 
structure  of  the  organs  or  from  traumatic  occlusion  of  the  efferent  ducts. 
The  semen  may  be  secreted  in  proper  quantity  and  of  a  healthy  quality,  yet 
it  may  be  prevented  in  some  manner  from  reaching  the  mouths  of  the 
ejaculatory  ducts.  This  condition  is  more  frequent  than  is  generally  sup- 
posed, it  being  difficult  of  detection  on  account  of  the  fact  that  impotency 
is  'not  necessarily  associated  with  it,  and  the  sexual  orgasm  is  attended  by 
the  ejaculation  of  secretions  from  various  portions  of  the  sexual  tract  that 
collectivel}^  resemble  semen,  and  which  under  normal  circumstances  form  an 
important  component  part  of  the  bulk  of  that  fluid. 

As  already  stated,  the  relation  of  gonorrhea  or  urethritis  to  sterility  is 
a  very  important  one.  Epididymitis  is  attended  by  the  exudation  of  inflam- 
matory lymph  in  and  about  the  epididymis.  This  may  be  speedily  absorbed, 
or  may  become  organized  into  connective  tissue  that  subsequently  contracts 
and  completely  obliterates  the  tubes  of  the  epididymis — a.  condition  that 
most  effectually  prevents  the  escape  of  semen  from  the  testes  into  the  vas 
deferens.  AVhen  consulted  regarding  matrimonial  imfruitfulness,  the  phy- 
sician should  carefully  inquire  of  the  husband  as  to  the  existence  at  some 
previous  time  of  double  epididymitis.  The  explanation  of  the  apparent 
sterility  of  the  wife  may  not  be  satisfactorily  determined  until  after  a  micro- 
scopic examination  of  the  semen  of  the  husband  has  been  made. 

Injuries  to  the  prostatic  urethra  incident  to  operations  upon  stricture 


572  STEEILITT   IN    THE    MALE. 

or  stone  in  the  bladder  may  produce  occhision  of  the  months  of  the  ejacu- 
latory  ducts  and  consequent  sterility.  Cauterization  of  the  prostatic  sinus 
may  result  in  a  similar  condition.  A  well-known  French  writer  observed, 
regarding  the  use  of  the  porte-caustique  by  Lallemand,  that  by  its  use  many 
men  had  been  unsexed.  It  is- to  be  remembered  that  sterility  in  the  male 
may  be  attended  by  absolutely  no  s)'^mptoms  that  will  lead  to  a  satisfactory 
diagnosis  without  resort  to  the  microscope.  Both  seminal  ducts  may  be  oc- 
cluded, so  that  the  semen  cannot  by  any  possibility  pass  through  the  ejacu- 
latory  ducts,  yet,  if  the  testes  are  Avell  developed  and  firm  and  in  a  perfectly 
normal  condition,  sexual  desire,  power  of  creation,  and  pleasurable  sensa- 
tions are  normal.  When  these  phenomena  are  natural,  yet  spermatozoa 
are  not  emitted,  it  is  usually  safe  to  infer  that  there  is  mechanic  obstruc- 
tion to  the  escape  of  semen  from  the  testes,  rather  than  a  secretory  per- 
turbation, even  though  these  organs  and  their  ducts  present  no  evidences 
of  disease. 

The  gross  appearance  of  the  fluid  ejaculated  during  the  sexual  orgasm 
in  azoospermia  may  be  almost  precisely  similar  in  appearance  to  normal 
semen,  the  absence  of  spermatozoa  alone  constituting  its  principal  clinical 
feature.    As  a  rule,  hoAvever,  the  fluid  is  thin  and  Avatery. 

Men  who  are  suffering  from  pronounced  stricture  of  the  urethra  are 
apt  to  be  sterile,  as  a  consequence  of  interference  AAdth  ejaculation  of  the 
semen.  In  eases  of  stricture  of  long  duration,  sterility  may  persist  for  some 
time  after  the  urethral  obstruction  has  been  removed.  This  is  due  to  the 
fact  that  the  obstruction  to  ejaculation  has  resulted  in  the  semen's  being 
habitually  forced  backward  into  the  bladder  past  the  veru  montanum,  the 
function  of  which  is  to  prevent  such  backward  passage  under  ordinary  press- 
ure and  to  facilitate  the  extrusion  of  the  spermatic  fluid  from  the  urethra. 
It  is  said  that  there  exists  in  Paris  a  certain  class  of  prostitutes  Avho  pre- 
A'ent  conception  by  passing  the  index  finger  into  the  rectum  of  the  male 
during  intercourse,  and  pressing  upon  the  membranous  urethra  just  in  front 
of  the  prostate  at  the  moment  of  ejaculation.  This  ingenious  and  disgust- 
ing practice  causes  the  semen  to  be  forced  back  into  the  male  bladder  by 
overcoming  the  resistance  of  the  veru  montanum.  If  this  performance  be 
indulged  in  frequently,  the  function  of  this  erectile  structure  may  be  per- 
manently destroyed,  and  the  indiAadual  ever  after  ejaculate  his  semen  into 
his  own  bladder.  In  most  cases  of  pronounced  stricture  the  semen  is  re- 
tained in  the  urethra  until  erection  subsides,  Avhen  it  sloAvly  dribbles  away. 
In  hypospadias  and  epispadias  the  deformity  of  the  urethra  may  be  such  as 
to  prevent  the  extrusion  of  the  semen  far  enough  into  the  vagina  to  accom- 
plish impregnation.     Individuals  thus  affected  are  practically  sterile. 

A  further  and  excellent  illustration  of  potency  conjoined  AAdth  sterility 
is  a  ease  that  the  author  has  elseAAdiere  described  as  illustrative  of  the  effects 
of  pathologic  changes  in  the  epidid5'-mis.  A  tuberculous  testicle  was  removed 
from  this  patient,  and  in  a  feAV  months  chronic  inflammation  and  indura- 


ETIOLOGY    OF    STEKILITY   IN    THE    MALE.  573 

tion  occurred  in  the  remaining  organ.  As  a  consequence,  while  the  patient 
found  that  his  sexual  desire  and  power  were  very  much  stronger  than  prior 
to  the  operation,  he  stated  that  after  the  appearance  of  disease  in  the  re- 
maining organ  he  no  longer  had  emissions,  the  orgasm  being  apparently 
perfectly  normal  with  the  exception  of  the  absence  of  seminal  discharge. 
It  is  sometimes  very  difficult  to  determine  accurately  the  causes  of  a 
lack  of  fecundating  power  in  the  semen.  Thus,  the  spermatozoa  may  be 
absent  from  the  seminal  fluid  in  cases  in  which  there  is  no  history  of  in- 
flammatory trouble  with  the  testicle  or  other  causes  that  would  prevent  its 
formation  or  discharge. 

In  some  instances,  probably  from  constitutional  depression  or  cachexia, 
the  elaborated  semen  is  perverted  in  quality  and  deficient  in  quantity,  the 
vitalizing  element  being  either  absent  entirely  or  of  such  degenerate  con- 
stitution that  it  is  incapable  of  impregnating  the  ovule.  Spermatozoa  may 
be  present  at  one  time,  and  absent  at  another  in  certain  instances,  accord- 
ing to  the  constitutional  condition  of  the  patient  at  the  time.  In  one  case 
of  a  professional  man  of  the  author's  acquaintance,  sterility  had  existed  for 
a  number  of  years;,  the  semen,  being  examined  at  various  times,  was  found 
to  contain  no  spermatozoa,  yet  they  finally  appeared  in  the  seminal  dis- 
charge, and  the  patient  succeeded  in  impregnating  his  wife. 

In  connection  with  the  subject  of  sterility  the  varying  vitality  of  both 
ovule  and  spermatozoa  must  be  taken  into  consideration.  As  is  well  known, 
there  is  no  constant  relation  between  the  performance  of  the  sexual  act  and 
the  discharge  of  the  ovule.  It  is,  therefore,  necessary,  in  order  that  im- 
pregnation may  be  facilitated,  that  both  the  male  and  female  elements  be 
capable  of  retaining  their  vitality  for  a  certain  length  of  time.  Obviously, 
if  this  were  not  the  case,  it  would  be  necessary  for  copulation  and  ovula- 
tion to  occur  simultaneously.  By  a  wise  provision  of  Xature,  however,  both 
ovule  and  spermatozoa  retain  their  vitality  for  a  considerable  time.  It  has 
been  claimed  by  some  physiologists  that  their  vitality  is  preserved  for  a  week 
or  ten  days,  or  even  longer.  If  during  the  persistence  of  this  vitality  the 
male  and  female  elements  are  brought  in  contact,  impregnation  is  likely  to 
occur.  Anything  that  lessens  the  period  during  Avhich  the  elements  neces- 
sary to  conception  retain  their  vitality  tends  to  produce  sterility.  In  some 
females  it  is  necessary  for  copulation  to  take  place  either  Just  before  or 
shortly  after  menstruation,  in  order  that  conception  may  occur.  The  mid- 
period  is  necessarily  the  least  favorable  to  conception,  for  at  this  time  the 
ovule  has  reached  its  minimum  degree  of  vitality,  if,  indeed,  it  has  not  al- 
ready become  disintegrated.  Between  this  period  and  the  next  ovulation 
a  sufficient  time  will  have  elapsed  to  impair,  or  perhaps  destroy,  the  vitality 
of  the  spermatozoa.  The  sources  of  fallacy  in  taking  this  fact  as  a  basis  for 
precautions  against  pregnancy  are  the  varying  vitality  of  the  ovule  and 
spermatozoa  and  the  fact  that  ovulation  is  probably  not  necessarily  coin- 
cident with  menstruation;   indeed,  ovulation  mav  occur  at  the  time  of  the 


574  STERILITY    IX    THE    MALE. 

sexual  act  as  a  result  of  extreme  sexual  excitement.  These  physiologic 
facts  are  worth}^  of  consideration  in  the  management  of  some  cases  of  steril- 
ity. For  example,  if  copulation  be  permitted  only  just  before  and  after 
menstruation,  the  sexual  energies  of  both  parties  to  the  act  are  conserved 
and  made  more  actiye.  The  sexual  passion  is  stronger  in  the  female  at  this 
time,  and,  if  the  male  is  abstinent  at  other  times,  he  too  is  apt  to  be  more 
passionate  and  vigorous.  By  taking  this  precaution  the  ovum  and  sperma- 
tozoa will  be  brought  in  contact  at  the  time  when  the  vitality  of  both  is  at 
its  maximum. 

Leaving  the  question  of  impotence  out  of  consideration,  it  is  a  well- 
known  fact  that  sterile  marriages  are  occasionally  observed  where  both  hus- 
band and  wife  are  perfectl}^  capable  of  procreation,  yet  for  some  peculiar 
reason  the  elements  necessary  for  conception  have  apparently  no  affinity  for 
each  other,  and  this  independently  of  the  question  of  sexual  passion.  The 
truth  of  this  assertion  is  shown  by  the  fact  that  in  many  instances  indi- 
viduals who  have  been  childless  in  a  first  marriage  have  married  again,  and 
have  reared  large  families.  The  physiologic  question  involved  under  these 
circumstances  is  well  recognized  by  stock-breeders,  who  find,  for  example, 
that  certain  mares  cannot  be  fecundated  by  a  stallion  that  is  perhaps  dis- 
tinguished by  the  multiplicity  of  his  progeny,  but  are  readily  impregnated 
when  covered  by  another  and  perhaps  inferior  stallion. 

It  is  conceivable  that  varying  states  of  vitality  of  the  spermatozoa  may 
result  from  morbid  condition  affecting  the  general  health.  Perfection  of 
elaboration  of  the  various  secretions  of  the  body  depends  greatly  on  the  con- 
dition of  the  individual.  It  is  well  known  that  the  secretions  of  the  salivary, 
mammary,  and  gastro-intestinal  glands  are  greatly  modified  by  mental  emo- 
tions, and  by  various  pathologic  conditions  affecting  the  system  at  large, 
and  why  may  not  this  be  equally  true  as  regards  the  semen?  It  is  probable 
that  the  condition  of  the  emotional  faculties  at  the  time  of  copulation  have 
much  to  do  with  fertility  in  the  human  subject.  This  is  one  of  the  pos- 
sible explanations  of  the  infrequency  of  conception  in  prostitutes. 

Abuse  of  the  sexual  apparatus,  either  through  masturbation  or  sexual 
excess,  next  to  inflammatory  troubles  of  the  testicle  is  probably  the  most 
frequent  cause  of  sterility.  Prolonged  overstimulation  of  the  secreting 
structures  of  the  testes  finally  results  in  exhaustion  and  relaxation  of  the 
organs,  the  semen  being  imperfectly  elaborated,  even  though  its  quantity 
and  consistency  may  be  apparently  the  same.  Again,  the  frequent  shocks 
to  the  nervous  system  involved  in  the  oft-recurring  orgasm,  in  combination 
with  the  drain  afforded  by  the  excessive  loss  of  seminal  secretion,  results  in 
constitutional  debility;  and  this  again,  reacting  upon  the  semen,  devitalizes 
it.  The  important  relation  that  the  bodily  condition  bears  to  the  number 
and  constitution  of  the  spermatozoids  can  hardly  be  overestimated.  Other 
things  being  equal,  the  activity  and  potency  of  the  spermatic  cells  is  in 
direct  proportion  to  the  strength  and  vigor  of  the  general  system. 


IMPOTENCE    IN    THE    MALE.  0  7o 

Diagnosis. — The  diagnosis  of  sterility  in  the  male  can  be  made  only 
by  examination  of  the  ejaculated  discharge.  When  the  spermatozoids  are 
found  to  be  absent,  feeble,  imperfectly  formed,  or  few  in  number,  the 
source  of  the  infecundity  of  the  individual  is  at  once  apparent.  Careful 
physical  examination  of  the  testicles  and  spermatic  cords,  with  exploration 
of  the  urethra,  may  demonstrate  the  fact  that  the  trouble  is  not  defective 
elaboration  of  semen,  but  obstructive,  the  semen  being  prevented  from 
escaping  into  or  from  the  urethra.  This  is  the  only  logical  inference  if  the 
testes  are  firm  and  hard  and  of  the  proper  size,  the  spermatic  cords  being 
also  apparently  healthy. 

Treatment. — The  treatment  of  sterility  in  the  male  is  unfortunately 
unsuccessful  in  a  large  proportion  of  cases.  Chronic  inflammatory  con- 
ditions of  the  epididymis  may  sometimes  be  removed  hj  measures  that 
will  be  suggested  later  in  the  consideration  of  diseases  of  the  testicle. 
Electricity  is  perhaps  the  most  reliable  remedy  at  our  command  for  these 
conditions.  Tonics,  proper  food,  and  attention  to  sexual  hygiene  may  occa- 
sionally accomplish  the  desired  result.  It  must  be  confessed  that  there  are 
many  cases  in  which,  however  faithfully  we  may  seek  for  the  cause  of 
sterility,  it  escapes  observation,  and  the  case  is  consequently  absolutely  in- 
curable. Some  of  the  conditions  that  obstruct  the  passage  of  the  semen 
from  the  urethra  may  be  removed,  stricture  being  the  morbid  state  that 
is  especially  amenable  to  treatment.  Certain  cases  of  deformity  of  the  penis 
may  be  cured  by  operation,  and  sterility  thus  corrected. 

impotence    in   THE    MALE. 

In  the  majority  of  cases  of  impotence  there  is  apparently  a  normal,  or, 
at  most,  merely  a  debilitated  and  flaccid  condition  of  the  generative  ap- 
paratus, but  the  patient  is  unable  to  obtain  an  erection.  The  lack  of  power 
varies  in  degree  from  a  condition  in  which  there  is  absolutely  no  manifesta- 
tion of  the  ph3''siologic  function  of  erection  to  cases  in  which  the  erection 
is  partial,  but  insufficient  for  copulation.  In  some  instances  erection  is 
perfect,  but  of  a  transitory  character,  ejaculation  occurring  prematurely. 
Care  should  be  taken  to  differentiate  the  cases,  else  treatment  is  not  apt 
to  be  successful.  Clinically  it  will  be  found  that  cases  of  impotency  may  be 
divided  into: — 

1.  Those  in  which  virility  is  impaired  by  general  constitutional  de- 
bility or  exhaustion  of  nervous  force,  the  lack  of  sexual  vigor  being  func- 
tional and  secondary  to  the  general  disturbance.  These  cases  may  depend 
upon  sexual  excess  or  masturbation,  which  produce  both  local  and  general 
debility.  They  may  or  may  not  be  associated  with  spermatorrhea,  nocturnal 
emissions,  etc. 

2.  Those  in  which  the  patient  is  strong  and  vigorous,  his  testes  secret- 
ing actively,  and  his  vesiculce  seminahs  being  overdistended  as  a  conse- 


576  IMPOTENCE    IN    THE    MALE. 

quence  of  infrequent  indulgence.    In  these  cases  premature  ejaculation  and 
a  transitory  character  of  erection  are  the  principal  features. 

3.  Those  in  whicli^  as  a  consequence  of  masturbation  or  sexual  excess, 
there  exists  hyperesthesia  of  the  floor  of  the  prostatic  urethra.  Imperfect 
secretion  and  premature  ejaculation  characterize  these  cases. 

4.  Cases  in  which  there  exists  some  pathologic  condition  of  the  sexual 
apparatus  that  acts  by  disturbing  innervation  and  producing  mental  de- 
pression, chiefly  from  the  moral  efllect  of  the  condition. 

5.  Those  in  Avhich  deformity  or  acquired  disease  interferes  with  erec- 
tion, completely  or  partially  preventing  it. 

6.  Those  in  which  congenital  malformations,  injury,  disease,  or  sur- 
gical operation  have  impaired  or  destroyed  the  structure  of  the  sexual  ap- 
jDaratus  to  an  extent  sufficient  to  prevent  copulation. 

Some  of  these  conditions  are  amenable  to  treatment,  while  others  are 
unfortunately  beyond  the  reach  of  medical  art. 

Impotence  is  divided  for  description  into  the  false  and  true  varieties. 

PsEUDO-iMPOTEXCE. — False  impotence  is  the  form  that  is  most  fre- 
quently seen,  and  is  usually  dependent  upon  causes  of  a  purely  mental  or 
moral  character,  the  sexual  organs,  so  far  as  can  be  determined  by  exam- 
ination, being  perfectly  healthy.  Individuals  sufl'ering  from  this  form  of 
impotence  are  usually  of  a  highly  impressionable  nervous  temperament 
primarily,  or  have  become  so  as  a  consequence  of  masturbation  or  sexual 
excesses.  Some  men  who  are  apparently  perfectly  healthy  flnd  themselves 
unable  to  perform  the  act  of  copulation  as  a  consequence  of  a  lack  of  con- 
fidence due  to  a  recollection  of  early  indiscretions  and  an  exaggerated  esti- 
mate of  their  effects.  Ignorance  of  sexual  physiology  is  often  the  founda- 
tion for  this  form  of  impotence.  Failure  to  accomplish  the  act  of  sexual 
intercourse  is  sometimes  due — paradoxic  as  it  may  seem — to  extraordinary 
vigor  and  secretory  activity  of  the  sexual  apparatus.  Individuals  who  have 
masturbated  but  little,  or  perhaps  none  at  all,  and  who  have  never  attempted 
sexual  intercourse  until  they  have  attained  their  majorit}^  are  frequently 
troubled  in  this  manner.     The  author  recalls  several  cases  of  this  kind: — 

Case  1.- — A  young  professional  man  30  years  of  age,  a  fine,  healthy-appearing 
subject  as  could  be  imagined.  He  had  masturbated  but  little  as  a  boy,  and  after 
attaining  adult  age  became  very  fond  of  the  society  of  women  and  acquired  the 
reputation  of  being  something  of  a  roue,  yet  he  assured  the  author  that  he  had 
never  been  able  to  accomplish  the  act  of  copulation,  premature  ejaculation  having 
attended  every  attempt — such  attempts  having  been  made  at  very  infrequent  inter- 
vals. He  seemed  to  think  that  there  Avas  some  organic  disease,  either  of  the  sexual 
organs  or  "of  the  blood,"  that  inhibited  his  sexual  powers.  Examination  showed  that 
the  sexual  organs  were  perfectly  healthy.  On  careful  interrogation  he  said  that  he 
had  never  attempted  intercourse  twice  consecutively,  but  had  become  thoroughly 
disgusted  by  his  first  failure  on  each  occasion.  It  seemed  that  intercourse  had  always 
been  attempted  under  circumstances  involving  not  only  extreme  sexual  excitement, 
but  more  or  less  uneasiness  as  regards  the  possibility  of  detection.  All  possible  means 
were  tried  to  convince  this  patient  that  he  was  perfectly  sound,  and  sexually  potent, 


ETIOLOGY    OF    PSEUDO-IMPOTEXCE    IN    THE    MALE.  5?? 

but  without  result.  He  still  entertains  the  opinion  that  he  is  impotent,  and  nothing 
but  success  in  copulation,  which  will  certainly  be  achieved  if  the  act  is  ever  attempted 
under  proper  circumstances,  will  ever  convince  him  to  the  contrary.  Overdistension 
of  the  seminal  vesicles,  in  combination  with  overexcitement  and  consequent  hyperes- 
thesia of  the  prostatic  sinus  existing  at  the  time  of  attempted  copulation,  is  the 
explanation  of  the  pseudo-impotency  of  this  individual. 

Case  2.- — A  similar  case  that  recently  came  under  observation  is  much  more 
tractable.  This  patient  states  that  he  has  never  masturbated  and  had  never  attempted 
intercourse  until  past  the  age  of  25.  He  is  of  an  exceedingly  passionate  temperament, 
and  has  found  that  he  has  never  been  able  to  accomplish  the  act  at  a  first  or  even 
a  second  attempt,  but  that  if  he  attempted  the  act  repeatedly  with  a  person  with 
whom  he  had  the  opportunity  of  associating  for  several  days  at  a  time,  he  finally 
succeeded,  and  was  thereafter  in  a  perfectly  normal  condition.  The  persistency  of 
this  individual  is  all  that  has  saved  him  from  the  same  despairing  frame  of  mind  as 
that  Avhich  exists  in  the  previous  case. 

The  form  of  impotency  born  of  excessive  and  uncontrolled  desire  has 
been  familiar  from  time  immemorial.  Three  centuries  ago  Montaigne 
dilated  upon  it  in  his  philosophic  essays  as  follow's: — 

Xeither  is  it  in  the  height  and  greatest  fury  of  the  fit  that  we  are  in  a  con- 
dition ...  to  sally  into  courtship,  the  soul  being  at  that  time  overburthened 
and  laboring  with  profound  thoughts,  and  the  body  dejected  and  languishing  with 
•desire;  and  hence  it  is  that  sometimes  proceed  those  accidental  impotencies  that 
so  unreasonably  surprise  the  willing  lover,  and  that  frigidity  which  by  the  force  of 
an  immoderate  ardor  so  unhappily  seizes  him  in  the  very  lap  of  fruition;  for  all 
passions  that  suffer  themselves  to  be  relished,  and  digested  are  but  moderate. 

The  surgeon  is  not  infrequently  called  upon  for  relief  for  just  such 
impotencies  as  Montaigne  so  clearly  describes.  That  the  remedy  is  better 
psychic  control  goes  without  saying. 

Continence  as  a  cause  of  true  impotence  has  been  admitted  by  some 
writers.  Howe  relates  two  interesting  cases  that  were  apparently  due  to 
this  cause^: — 

Case  1. — In  the  winter  of  1876  an  undertaker  of  this  city  was  admitted  to 
St.  Francis  Hospital,  suffering  from  prolapse  of  the  rectum.  He  was  45  years  old 
and  his  general  health  was  good.  After  recovering  from  the  prolapse  he  informed  me 
that  he  Avas  impotent,  and  likewise  was  subject  to  nocturnal  emissions.  During  the 
whole  course  of  his  life  he  had  refrained  from  any  gratification  of  his  passions,  and 
had  never  attempted  sexual  intercourse  until  within  the  past  year.  Twelve  months 
previous  to  his  admission  he  had  married,  and  without  expecting  anything  of  the 
kind  found  himself  impotent  and  unable  to  consummate  the  marriage.  Every  attempt 
at  intromission  failed,  through  weak  erections  and  rapid  emissions.  He  denied  mastur- 
bation, and  the  condition  of  the  genitals  seemed  to  confirm  his  statement.  From  the 
age  of  25  he  had  emissions  once  a  fortnight  and  frequent  erections,  but  the  erections 
were  feeble,  and  lasted  only  for  a  few  moments.  Since  his  marriage  the  emissions  had 
increased  in  frequency,  and  there  seemed  to  be  much  relaxation  and  apparent  elonga- 
tion of  the  penis.    The  patient  did  not  seem  to  be  depressed  by  the  fact  of  his  impotence. 


^  "Excessive  Venerv,"  etc. 


578  IMPOTENCE    IN    THE    MALE. 

He  attributed  it  all  to  total  abstinence,  and  hoped  that,  in  the  course  of  time,  Xature 
would  effect  a  cure. 

The  author  does  not  believe  that  continence  per  se  ever  causes  true 
impotence.  The  cases  in  which  it  apparently  does  so  are  usually  either 
masturbators  or  congenitally  weak,  or  both. 

A  few  cases  are  recorded  by  Lallemand  and  others  where  rectal  disease  caused 
temporary  impotence,  but  the  patients  were  not  continent,  and  they  recovered  from  the 
spermatorrhea  and  impotence  when  the  prolapse  was  cured.  In  the  patient  whose 
history  has  just  been  given  the  prolapse  of  the  rectum  may  have  added  to  the  genital 
weakness,  but  it  was  probably  not  the  cause  of  it. 

Howe  records  a  second  interesting  case  of  impotence  from  continence, 
unaccompanied  by  spermatorrhea: — 

Case  2. — The  patient  was  38  years  old,  and  a  broker  by  occupation.  His  general 
health  was  excellent,  and  he  was  constantly  and  actively  employed  in  a  flourishing 
business.  He  commenced  to  masturbate  a  little  when  a  boy  of  12,  and  occasionally 
was  guilty  of  the  habit  until  he  reached  the  age  of  16,  at  which  time  he  discontinued 
it  altogether.  At  twenty  he  had  intercourse  in  a  natural  way,  and  without  any 
difficulty  whatever.  For  six  months  subsequently  he  cohabited  at  intervals  of  two 
weeks,  and  never  at  any  time  indulged  to  excess.  A  period  of  eight  years  then 
elapsed  without  any  opportunity  for  sexual  congress.  At  the  termination  of  that 
period  he  again  attempted  to  renew  his  sexual  relations  with  his  former  partner,  but, 
to  his  great  annoyance,  failed.  Though  he  subsequently  made  frequent  trials,  the 
result  was  the  same.  He  finally  gave  up  all  hope,  firmly  believing  that  his  impotence 
was  beyond  the  reach  of  therapeutic  agents.  He  attributed  his  loss  of  virility  to 
continence,  and  not  to  any  dissipation  or  bad  habits  in  early  life.  A  period  of  ten 
years  elapsed,  during  which  interval  he  tried  sexual  congress  but  once,  and  was  unsuc- 
cessful. He  had  few  emissions,  and  few  erections.  For  twelve  months  previous  to 
calling  at  my  office  he  had  had  only  three  emissions,  and  no  erections  of  any  degree 
of  permanence.  He  thought  his  desire  for  sexual  pleasures  had  not  diminished,  but,  the 
knowledge  of  his  impotence  being  ever  present,  would  prevent  him  from  attempting 
it  again.  This  mental  state  necessarily  complicated  his  case,  and  added  to  the  difficulty 
of  a  cure.  On  making  an  examination  of  his  genital  organs  I  found  the  penis  and 
testicles  somewhat  smaller  than  natural.  The  left  testicle  was  smaller  than  the  right, 
and  more  than  ordinarily  sensitive  to  pressure.  Otherwise  the  parts  were  unchanged. 
Knowing  that  the  patient's  habits  were  excellent,  and  that  his  general  health  was 
good,  I  made  a  favorable  prognosis,  and  put  him  under  treatment.  He  continued  under 
treatment  for  three  months,  improving  sloAvly.  His  erections  were  more  frequent  and 
natural,  and  his  hopes  of  final  recovery  revived.  He  suddenly,  without  any  notifica- 
tion, ceased  his  visits  at  the  office.  The  summer  following  he  consulted  me  for  gonor- 
rhea, and  informed  me  that  a  few  days  after  he  had  ceased  calling  he  renewed  his 
attempt  at  intercourse,  and  succeeded,  and  had  kept  well  in  that  respect  ever  since. 

The  author  has  seen  so  many  cases  similar  to  those  reported  by  Howe 
that  he  feels  warranted  in  the  belief  that  prolonged  continence  in  excep- 
tional cases  bears  a  definite  etiologic  relation  to  impotence.  As  already 
stated,  however,  he  does  not  believe  that  continence  alone  ever  causes  true 
impotence.  In  some  cases  the  patient's  statements  regarding  masturbation 
should  be  discounted.    It  is  nothing  unusual  for  patients  to  assert  that  they 


ETIOLOGY    OF    PSEUDO-IMPOTENCE    IN    THE    MALE.  579 

have  practiced  the  vice  "but  a  few  times,"  etc.,  when,  as  a  matter  of  fact, 
they  have  not  only  practiced  it  very  frequently,  but  are  not  yet  rid  of  the 
habit.  In  a  general  way,  however,  men  who  abstain  from  sexual  intercourse 
up  to  thirty  years  of  age  are  often  impaired  in  their  sexual  power — pseudo- 
impotence — whether  they  have  masturbated  or  not;  where  they  have  mas- 
turbated, especially  if  the  habit^has  not  been  broken,  impotence  is  common. 

It  should  be  remembered,  in  considering  the  subject  of  pseudo-im- 
potency,  that  the  sexual  passion  varies  in  intensity  in  different  individuals. 
Many  persons  are  of  frigid  temperament  and  are  apt  to  exhibit  more  or  less 
sexual  indifference.  This  is  usually  associated  with  a  relative  sluggishness 
of  the  sexual  apparatus,  which,  however,  is  perfectly  natural  to  the  particu- 
lar individual. 

A'ery  slight  mental  disturbances  at  the  time  of  attempted  intercourse 
may  result  in  temporary  impotence.  Anxiety  or  mental  worry  of  any  kind 
is  apt  to  give  rise  to  it.  Individuals  who  have  labored  mentally  or  phys- 
ically to  the  extent  of  producing  exhaustion  are  apt  to  experience  temporary 
inhibition  of  sexual  activity  and  desire.  This  physiologic  phenomenon  may 
be,  as  has  already  been  suggested,  taken  advantage  of  in  the  treatment  of 
sexual  disorders.  Emotional  influences  that  are  capable  of  making  a  pow- 
erful impression  upon  the  nervous  system  are  especially  apt  to  inhibit  sex- 
ual desire,  the  more  particularly  as  they  tend  to  check  the  secretion  of 
semen.  The  influences  that  tend  to  produce  activity  of  secretion  of  the 
testes  are  chiefly  emotional,  and,  conversely,  diverse  mental  influences  may 
check  the  secretion.  An  eminent  writer  ujDon  hysteria  outlined  this  fact 
as  follows^ : — 

The  glands  liable  to  emotional  congestion  are  those  which,  by  forming  their 
products  in  larger  quantity,  subserve  to  the  gratification  of  the  excited  feeling.  Thus, 
blood  is  directed  to  the  mammae  by  the  maternal  emotions,  to  the  testes  by  the  sexual, 
and  to  the  salivary  glands  by  the  influence  of  appetizing  odors;  while  in  either  case 
the  sudden  demand  may  produce  an  exsanguine  condition  of  other  organs,  and  may 
check  some  function  which  was  being  actively  performed,  as,  for  instance,  the 
digestive. 

The  emotion  of  fright  or  the  condition  of  mind  produced  by  the  fear 
of  detection  or  of  the  results  of  copulation  will  invariably  inhibit  the  sexual 
power.  Disgust,  indifference,  or  antipathy  for  the  party  of  the  second  part 
has  often  a  similar  effect. 

The  practical  physician  does  not  usually  put  much  faith  in  the  theory 
of  affinity  as  existing  between  the  sexes,  but  the  author  is  of  opinion  that 
in  many  instances  failure  to  consummate  the  marital  act  is  due  to  a  lack 
of  harmony  between  the  contracting  parties.  An  apparent  instance  of  this 
is  the  following: — 


^  Carter,  on  "Hysteria." 


580  lilPOTEXCE    IX    THE    MALE. 

Case. — A  man,  31  years  of  age,  perfectly  healthy,  the  sexual  organs  being 
perfectly  formed  and  apparently  in  a  normal  condition,  came  to  the  author  for  relief 
of  impotence.  He  was  a  man  of  very  highly-wrought  nervous  organization,  and  had 
never  been  anything  of  a  roue.  The  only  possible  exception  that  could  be  taken  to 
his  physical  condition  was  the  fact  that  he  was  somewhat  inclined  to  corpulence.  He 
stated  that  he  had  not  experienced  an  erection  for  some  months.  During  this  time, 
however,  he  had  been  working  very  hard,  and  had  not  allowed  his  mind  to  dwell  on 
sexual  matters,  and  he  himself  was  inclined  to  attribute  the  absence  of  erections  to 
this  fact.  As  he  contemplated  matrimony,  however,  he  desired  a  course  of  treat- 
ment. On  inquiry  he  stated  that  he  had  on  several  occasions  failed  in  accomplishing 
intercourse,  but  that  he  had  found  that  with  certain  females  he  was  perfectly  potent, 
while  with  others  he  was  absolutely  impotent.  He  ^^as  assured  that  there  was  no 
physical  impediment  to  matrimony,  and  a  course  of  local  faradization  was  advised. 
He  improved  very  rapidly,  and  in  a  few  months  the  sexual  function  became  so 
active  that  the  bougie  electrode  could  not  be  passed  because  the  slightest  contact  with 
the  urethra  produced  vigorous  erection.  He  stated  that  when  he  took  a  Turkish 
bath,  as  per  advice,  he  was  considerably  embarrassed  by  the  occurrence  of  erections 
so  soon  as  the  attendant  attempted  to  rub  him.  Under  these  circumstances  the 
author  felt  perfectly  justified  in  advising  matrimony.  The  result  was  unfortunately 
not  what  had  been  expected,  for  a  year  after  marriage  he  had  not  yet  succeeded  in 
accomplishing  intercourse.  There  was  evidently  in  this  case  some  inhibitory  cause 
of  a  mental  character,  as  shown  by  the  fact  that  after  marriage  he  still  had  vigorous 
erections  and  nocturnal  emissions  with  dreams.  As  soon  as  the  idea  of  attempting 
intercourse  entered  his  mind  he  found  it  absolutely  impossible  to  secure  an  erection. 
The  author  finally  succeeded  in  curing  this  case  by  the  exercise  of  a  little  ingenuity. 
The  Mife  was  sent  away  for  three  months,  the  husband  being  meanwhile  treated  with 
electricity.  On  the  day  of  the  wife's  home-coming  the  patient  was  provided  with  a 
rectal  suppository  containing  a  little  belladonna,  opium,  and  camphor.  He  was  in- 
structed to  insert  this  on  going  to  bed  and  was  assured  that  the  wonderful  suppository 
never  failed.  The  treatment  was  a  brilliant  success  and  there  was  no  future  trouble, 
the  wife  becoming  pregnant  within  a  few  weeks. 

The  fact  that  certain  individuals  of  highly-sensitiye  nervous  organiza- 
tion are  impotent  respeetiug  some  women,  while  with  others  they  are  per- 
fectly potent,  is  a  well-known  fact.  Individuals  of  this  sort  are  rery  often 
convinced  that  they  are  impotent.  Ijy  failure  in  experimenting  with  prosti- 
tutes for  the  purpose  of  determining  whether  or  not  they  are  justified  in 
assuming  the  matrimonial  state.  The  fact  that  they  are  impotent  under 
such  circumstances  is  highly  complimentary  to  their  moral  tone.  The  en- 
vironment that  surrounds  the  average  prostitute,  in  conjunction  with  the 
purely  mercantile  character  of  the  transaction,  is  not  likely  to  inspire  w^ith 
sexual  passion  an  individual  possessed  of  the  average  amount  of  decency  and 
self-respect.  It  is  not  unusual  for  individuals  to  state  that,  excepting  when 
under  the  influence  of  liquor,  they  are  ahsolutely  impotent  with  prostitutes. 
Considerahle  and  forcible  argument  may  be  necessary  to  convince  patients 
who  have  applied  what  they  consider  the  crucial  test  of  attempting  inter- 
course with  jirostitutes.  and  have  failed,  that  they  are  not  impotent. 

Boubaud  records  a  case  which,  although  it  has  become  so  extensively 
Cjuoted  bv  writers  upon  the  subject  that  it  has  been  worn  almost  thread- 


ETIOLOGY    OF    PSEUDO-IMPOTENCE    IN    THE    MALE.  581 

bare,  is  nevertheless  very  pertinent  as  applied  to  patients  who  are  psychically 
impotent  with  some  women,  while  perfectly  potent  with  others: — 

Case. — M.  X.,  son  of  a  general  of  the  First  Empire,  was  brought  up  at  his  father's 
country-seat,  which  he  did  not  leave  until  he  was  eighteen  years  of  age,  Avhen  he 
went  to  the  military  school.  During  his  long  period  of  isolation  in  the  country  he 
had  been  initiated,  at  the  age  of  fourteen,  into  an  experience  of  the  pleasures  of  love, 
by  a  young  lady,  a  friend  of  the  family.  This  lady,  then  twenty-one  years  old, 
was  a  blonde;  wore  her  hair  in  the  English  style,  that  is  to  say,  in  corkscrew  curls: 
and  in  order  to  lessen  the  liability  of  detection  in  her  amorous  intrigue,  she  never 
had  intercourse  with  her  young  lover  except  when  clothed  in  her  day  attire, — that 
is  to  say,  wearing  gaiter-boots,  corsets,  and  a  silk  gown. 

All  these  details  I  mention  purposely,  for  they  had  great  influence,  not  only 
over  the  degree  of  excitability  of  the  genital  function,  but  over  its  very  existence, 
in  the  case  of  M.  X. 

The  young  lady  was  of  strong  passions,  and,  as  it  appeared,  exhausted  the 
strength  of  the  young  neophyte,  and  the  severe  regimen  of  the  military  school  was 
no  more  than  sufficient  to  restore  to  the  genital  organs  the  energy  which  had  been 
seriously  affected  by  too  early  and  too  frequent  indulgence. 

But  w-hen,  the  period  of  his  study  having  passed,  he  A^as  sent  to  a  garrison, 
and  was  disposed  to  enjoy  the  rights  w^hich  Nature  had  restored,  he  perceived  that 
sexual  desire  was  only  provoked  by  certain  women  and  with  the  concurrence  of 
certain  circumstances.  Thus,  a  brunette  did  not  produce  in  him  the  slightest  emo- 
tion, and  a  woman  in  her  night-dress  was  sufficient  to  extinguish  and  freeze  every 
amorous  transport. 

In  order  that  he  might  experience  the  venereal  desire,  it  was  necessary  that  the 
woman  should  be  blonde,  should  wear  gaiter-boots,  should  be  laced  in  a  corset,  wear 
a  silk  gown,  and,  in  a  word,  fulfill  all  the  requirements  of  the  lady  who  had  first 
caused  M.  X.  to  experience  the  sexual  orgasm. 

And  this  was  not  by  reason  of  any  sentimental  love,  the  magic  power  of  which 
lasts  through  a  life-time.  In  his  early  sexual  relations  M.  X.  had  only  been  actuated 
by  animal  desire.  His  heart  had  never  been  touched,  and  after  twenty-five  years,  in 
consulting  me  for  his  singular  infirmity,  he  declared  that  he  had  loved  with  his 
heart  but  one  \\'oman,  and  to  her  he  had  never  been  able  to  render  homage,  for,  by  a 
perverse  coincidence,  she  was  a  brunette. 

His  fortune,  his  name,  his  social  position,  made  it  the  duty  of  M.  X.  to  marry,  but 
he  had  always  resisted  the  solicitations  of  his  family  and  friends,  knowing  that  he 
would  be  incapable  of  availing  himself  of  his  marital  rights,  with  a  wife  arrayed  in 
the  costume  of  the  nuptial  bed.  Yet  he  was  in  good  health,  Avas  of  the  sanguino- 
choleric  temperament,  was  above  the  medium  height,  and  was  of  so  strong  a  consti- 
tution that  for  fifteen  years  he  had  been  an  officer  in  a  regiment  of  heavy  cavalry. 

Evidently  his  impotence  was  relative  only,  for,  w'hen  the  woman  was  blonde 
and  when  the  other  conditions  specified  existed,  he  accomplished  the  sexual  act  with 
all  the  ardor  of  a  healthy  man  of  amorous  disposition. 

Eoiibaucl  finally  cured  this  patient  by  suggestion,  in  conjunction  with 
the  use  of  alcoholic  stimulants  to  the  point  of  mild  intoxication.  The  spell 
once  broken,  there  was  no  further  trouble. 

Such  psychosexual  inhibitions  as  the  case  related  by  Eoubaud  are  more 
frequent  than  is  generally  supposed.  Prolonged  sexual  relations  with  an 
individual  of  a  certain  type  not  infrequently  makes  such  a  profound  psychic 


582  IMPOTENCE    IN    THE    MALE. 

impression  that  other  types  of  women  are  unattractive.  Especially  is  this 
true  of  men  of  tine  nervous  organization  who  happen  to  consort  with  women 
of  decided  blonde  or  brunette  type.  Prolonged  association  with  one  type  by 
no  means  rarely  makes  the  other  unattractive,  sometimes  even  repellant. 
This  is,  of  course,  not  always  a  mere  matter  of  physique.  Certain  intel- 
lectual attributes  in  the  woman  may  have  much  to  do  with  the  psycho- 
sexual  impression  she  produces. 

Cases  have  been  noted  in  which  pseudo-impotence  was  relieved  by  the 
affected  individual's  picturing  in  his  imagination  the  person  of  some  woman 
other  than  the  one  with  whom  he  was  attempting  to  cohabit.  In  certain  im- 
pressionable individuals  impotence  may  result  from  a  lack  of  affinity  between 
the  parties  to  the  act,  actual  antipathy  on  the  part  of  either  being  unneces- 
sary to  its  causation.  Goethe  took  advantage  of  this  physiologic  fact  in  his 
"Elective  Affinities.''  In  this  tale  is  described  the  mutual  enjoyment  ob- 
tained by  an  estranged  couple  through  the  medium  of  their  imaginations, 
each  party  to  the  act  imagining  the  other  to  be  the  individual  for  whom 
an  affinity  was  felt.  Goethe  carries  the  theory  of  affinity  still  further,  and 
describes  the  child  that  was  born  as  the  fruit  of  this  particular  conjugal  act 
as  in  nowise  resembling  its  parents,  but  presenting  a  strong  resemblance  to 
both  individuals  for  whom  the  parents  felt  an  affinity,  and  who  were  pres- 
ent in  imagination  at  the  time  of  conception. 

Hammond  relates  a  case  that  is  aptly  illustrative  of  the  manner  in 
which  certain  mental  conditions  will  produce  temporary  impotence: — 

Case.^A  married  gentleman,  who  before  entering  into  the  matrimonial  state, 
had  been  excessively  given  to  sexual  intercourse,  but  who  had  no  reason  to  think 
that  his  powers  were  exhausted,  or  even  materially  weakened,  found  himself  on 
his  wedding-night  and  for  some  days  thereafter  absolutely  incapable  of  consummating 
the  marriage.  His  wife  was  a  highly-educated,  intelligent,  refined,  and  beautiful 
woman;  he  w^as  devotedly  attached  to  her,  and  on  marrying  at  once  and  for  all 
gave  up  the  evil  associations  of  his  younger  days.  His  passions  were  strong,  but  as 
soon  as  he  attempted  intercourse  the  desire  he  had  previously  entertained  vanished 
at  the  thought  that  it  was  a  profanation  for  a  man  like  him  to  subject  so  beautiful 
and  pure  a  woman  to  such  an  animal  relation  as  sexual  intercourse.  "She  is  too 
good  for  me,"  he  would  say  to  himself;  "I  ought  to  have  married  a  woman  used 
to  this  sort  of  thing,  or,  better  still,  have  remained  single  and  gone  on  in  the  old 
way."  This  happened  several  times,  and  then,  in  disgust  with  himself,  he  paid  a 
visit  to  one  of  his  former  female  associates,  and  soon  satisfied  himself  that  his 
powers  were  as  good  as  ever.  Again  he  essayed  the  act  with  his  wdfe,  and  again 
he  met  with  disappointment. 

He  had  now  been  married  a  week,  and  the  marriage  was  still  unconsummated. 

A  case  like  this  presented  very  little  difficulty:  I  reminded  him  of  the  fact 
that  in  all  probability,  however  pure  and  noble  his  wife  might  be,  there  was  no 
profanation  in  sexual  intercourse,  chastely  undertaken;  that  she  had  sexual  organs 
which  were  intended  for  the  performance  of  certain  functions;  that  these  functions 
were  all  connected  with  the  propagation  of  the  human  species;  that  there  was  but 
one  way  that  I  knew  of  by  which  the  species  could  be  propagated;  that  she  had 
selected  him  as  the  man  who  Avas  to  put  her  in  the  Avay  of  fulfilling  her  office  in 


ETIOLOGY    OF   TEUE    IMPOTENCE.  583 

the  grand  scheme  of  Nature,  and  that  my  advice  to  him  was  to  lower  his  estimate  of 
her  angelic  character,  and  to  look  upon  her  in  the  not  less  worthy  light  of  a  woman 
to  be  treated  as  other  women  are  treated  under  like  circumstances.  He  left,  promis- 
ing to  be  less  exalted  in  appreciation,  but  the  next  morning  returned  with  the  in- 
formation that  it  was  no  use;  he  had  tried  his  best,  his  erections  were  strong  and 
repeated,  but  as  soon  as  he  went  further  toward  the  object  he  had  in  view  his  desire 
become  utterly  extinguished.  She  was  "too  good,  too  delicate,  for  a  mere  animal  like 
him;    he  could  not  desecrate  her  beautiful  body  by  any  such  vile  act,"  etc. 

With  the  sensible  co-operation  of  the  wife  Hammond  had  no  difficulty 
in  curing  this  case  by  suggestion. 

Sexual  perversion  may  cause  impotence.  It  is  obvious  that  individuals 
for  whom  the  natural  method  of  performance  of  the  sexual  act  has  no  at- 
tractions are  apt  to  fail  should  they  attempt  it.  Impotence  of  a  transitory 
character  may  be  due  to  the  psychic  effect  of  satiety  as  well  as  to  the  de- 
bilitating influence  of  sexual  excess.  This  is  the  form  of  impotence  most 
frequently  seen  in  married  men.  Through  resulting  psychic  perturbation, 
a  lack  of  responsiveness  on  the  part  of  the  female  is  an  occasional  cause 
of  pseudo-impotence  in  the  male.  This  is  particularly  apt  to  arise  in  mar- 
ried men  and  is  probably  in  the  majority  of  instances  primarily  their  own 
fault. 

Teue  Impotence. — True  impotence  is  rare  in  both  male  and  female; 
extremely  so  in  the  latter.  The  function  of  the  male  in  the  act  of  copula- 
tion is  an  active  one,  and  erection  of  the  sexual  member  is  necessary; 
whereas  in  the  case  of  the  female  no  preparation  is  necessary  for  the  sexual 
act,  her  function  being  comparatively  passive.  The  necessary  element  in 
the  case  of  the  male  is  a  sufficient  degree  of  firmness  of  erection  to  permit 
the  introduction  of  the  penis  into  the  vagina,  and  any  individual  who  is 
possessed  of  this  amount  of  capacity  cannot  justly  be  said  to  be  affected 
with  true  impotence.  It  is  unnecessary  to  potency  that  the  individual 
should  experience  either  desire  for,  or  pleasure  in  the  performance  of,  the 
act  of  copulation.  In  certain  conditions  perfect  erection  and  even  ejacula- 
tion are  possible,  although  the  individual  does  not  experience  either  desire 
or  pleasure.  Some  of  the  diseases  affecting  the  spinal  medulla  produce  this 
phenomenon.  In  certain  cases  of  aspermatism  a  similar  state  of  affairs  is 
noted.  Severe  priapism  due  to  cantharidal  poisoning  is  not  usually  attended 
by  sexual  desire,  and  intercourse  under  such  circumstances  may  be  abso- 
lutely devoid  of  pleasure. 

The  term  impotence  in  the  case  of  the  male  should  be  restricted  to 
those  cases  in  which  there  exists  some  actual  physical  impediment  to  the 
performance  of  the  act  of  copulation.  Such  impediment  may,  however,  be 
temporary  or  permanent. 

Etiology. — The  causes  of  true  impotence  may  be  classified  as  (a)  con- 
genital;  (b)  acquired. 

(a)  Congenital  Causes. — 1.  Marked  h3rpospadias  or  epispadias.  In 
some  cases  of  the  former  the  penis  is  curved  or  otherwise  deformed.    In  the 


584  IMPOTENCE    IN"    THE    MALE. 

latter  condition  exstrophy  of  the  bladder  ma}^  co-exist.    The  author  has  met 
"vrith  one  ease  of  impotence  due  to  a  congenital  lateral  curvature  of  the  penis. 

2.  Imperfect  development  of  the  penis  and  testes,  the  former  being  too 
small  and  too  flaccid  for  copulation.  Oftentimes  the  penis  seems  overlarge, 
yet  the  erectile  tissiie  is  not  well  developed,  and  erection  is  consequently 
imperfect. 

3.  Congeriitally-excessive  development  of  the  joenis  (?).  This  form  of 
impotence  may  be  only  a  relative  affair,  the  real  cause  being  a  dispropor- 
tionate smallness  of  the  vagina  of  the  individual  with  whom  intercourse  is 
attemj^ted.  In  the  absence  of  tumors  it  is  probable  that  the  cases  in  which 
the  penis  is  too  large  to  permit  of  copulation  are  extremel}''  rare,  if,  indeed, 
they  ever  occur. 

4.  CrA'ptorchidism  or  monorchidism,  with  imperfect  development  of 
the  penis. 

5.  Excessive  redundancy  of  the  prepuce,  with  phimosis. 

6.  Congenital  tumors  of  the  organ. 

(b)  Acquired  Causes. — 1.  Tumors  of  the  penis,  ^Drepuce,  or  glans. 

2.  Inflammatory  thickening  of  the  prepuce,  with  phimosis,  incidental 
to  balanitis,  gonorrhea,  or  chancroid. 

3.  Large  venereal  vegetations. 

4.  Excessive  obesity.  This  cause  is  frequent,  but  is  sometimes  over- 
come by  the  ingenuity  of  the  patient  in  reversing  the  relative  positions  of 
the  male  and  female  during  copulation:  an  expedient  as  old  as  the  De- 
cameron.    Obesit}^  also  lessens  desire. 

5.  Ankylosis  of  both  hips  may  prevent  copulation  in  the  normal  man- 
ner, although  by  appropriate  posturing  the  act  may  be  accomplished,  at 
least  by  the  male. 

6.  Tumors  of  the  scrotum  or  testes,  such  as  hydrocele,  sarcocele,  he- 
matocele, cancer,  and  elephantiasis.  The  two  latter  conditions  may  involve 
the  penis. 

7.  Chancre  or  chancroid  of  the  penis  of  sufficient  size  and  irritability 
to  interfere  with  copulation  by  the  pain  the  act  produces. 

8.  Gonorrheal  or  simple  urethritis. 

9.  Acute  or  chronic  chordee.  The  former  condition  occurs  in  gonor- 
rhea; the  latter  may  result  from  frequent  and  severe  attacks  of  urethritis, 
or  from  stricture,  and  may  occasionally  arise  as  a  consequence  of  ure- 
throtomy. 

10.  Inflammation  of  the  deep  urethra,  prostate,  and  seminal  vesicles. 

11.  Circumscribed  inflammation  of  the  corpora  cavernosa.  In  these 
cases  calcareous  plates  sometimes  form. 

12.  Cicatrices  from  wounds  of  the  penis  or  urethra,  interfering  with 
erection. 

13.  Eemoval  of  the  penis  and  testes.  If  the  operation  be  performed 
early  in  life  removal  of  the  latter  only  is  necessary. 


ETIOLOGY    OF   TEUE    IMPOTENCE.  585 

14.  The  habit  of  masturbation,  spermatorrhea  from  whatever  cause, 
nervous  shock,  and  in  some  instances  organic  disease  of  the  brain  and  spinal 
cord  may  produce  a  complete  and  permanent  loss  of  power  of  erection  by 
exhaustion  or  inhibition  of  the  nervous  stimulus  to  the  parts. 

15.  Temporar}'-  and  symptomatic  impotence  is  sometimes  the  result  of 
existing  constitutional  diseases,  su.ch  as  fevers.  Debilitating  and  prostrat- 
ing acute  or  chronic  disease,  and  neurasthenia  from  overwork  or  worry,  may 
produce  it.^ 

Certain  local  conditions  are  occasionally  attended  by  symptomatic  im- 
potence. Thus,  inflammation  of  the  testicles,  varicocele,  and  tumors  of  the 
testes  or  scrotum  other  than  those  that  are  capable  of  interfering  mechanic- 
ally with  the  act  of  copulation  may  produce  complete  impotence.  In  some 
instances  this  is  due  to  reflex  inhibition  of  the  sexual  power,  while  in  others 
the  condition  is  a  purely  mental  one,  resulting  from  the  moral  effect  of  the 
knowledge  of  the  existence  of  pathologic  conditions  of  the  sexual  apparatus. 
In  varicocele,  particularly,  both  elements  in  the  causation  of  impotence  de- 
serve consideration.  There  is  a  lack  of  tone — in  fact,  a  marked  debility  of 
the  generative  apparatus  in  many  instances — and  associated  with  this  ener- 
vation there  is  profound  mental  disturbance,  resulting  from  the  conscious- 
ness that  the  sexual  organs  are  not  healthy.  Syphilitic  orchitis  may  in  a 
similar  manner  produce  impotence,  and,  as  already  seen,  sterility.  If  this 
condition  be  not  speedily  relieved,  permanent  impotence  and  sterility  may 
result  as  a  consequeilce  of  changes  in  the  secretory  structure  of  the. testes 
incidental  to  the  pressure  of  the  syphilitic  neoplasm. 

Various  drugs  have  been  said  to  produce  impotence;  but  a  certain 
amount  of  skepticism  is  pardonable  in  this  connection.  It  certainly  must 
require  large  doses  of  the  various  sedative  and  alterative  drugs  to  bring 
about  this  condition.  Arsenic,  antimony,  lead,  iodin,  camphor,  and  hash- 
eesh are  among  the  drugs  that  are  said  to  produce  impotence.  Iodin  has 
been  accredited  with  the  power  of  producing  atrophy  of  the  testes.  The 
author  does  not  believe,  however,  that  a  single  authentic  case  can  be  pro- 
duced in  which  such  atrophy  is  justly  attributable  to  the  use  of  this  drug. 
One  explanation  for  the  popular  idea  that  the  potassium  iodid  is  capable 
of  producing  atrophy  of  the  testes  is  that  certain  cases  of  syphilitic  orchitis 
have  been  insufficiently  treated  with  the  drug,  or  treated  too  late.  Atrophy 
of  the  testicle  has  resulted,  not  from  the  drug,  but  from  pressure-innutri- 
tion produced  by  syphilitic  neoplasm  that  large,  and  long-continued  doses 
of  iodid  might  have  removed  in  time  to  save  the  testis.  The  carbonated 
waters  taken  in  excess  are  said  to  produce  impotence.  The  author  regards 
this  as  a  pleasing  delusion  on  the  part  of  "men  about  town." 


^  Vecki  ("Sexual  Impotence")  claims  that  a  severe  cold  produces  impotence  by 
inhibiting  olfaction.  The  author  admits  the  clinical  fact,  but  believes  the  temporary 
impotence  to  be  due  to  the  constitutional  effect  of  the  cold. 


586  IMPOTENCE    IN   THE    MALE. 

Ill  some  cases  of  impotence  it  is  impossible  to  attribute  the  condition 
to  any  particular  cause. 

Teeatment. — The  treatment  of  impotence  may  be  divided  into  (a) 
morale  (b)  medicinal  and  surgical.  The  latter  may  be  subdivided  into:  (1) 
general;    (2)  local. 

The  mainstay  of  treatment  in  false  or  nervous  impotence  consists  of 
psychotherapy.  The  principal  requirement  is  the  restoration  of  the  pa- 
tient's self-confidence.  The  greatest  delicacy  and  judgment  are  necessary 
in  the  management  of  these  cases.  The  patient  should  feel  that  his  ph};-- 
sician  S3^mpathizes  with  him  in  his  apparent  afHictioii.  It  will  not  do  to 
laugh  at  his  ailment,  or  to  treat  it  lightly,  even  though  assured  that  his 
impotence  is  imaginary  rather  than  real.  The  patient  is  usually  compara- 
tively strong  and  healthy,  but  has  masturbated  to  a  certain  extent  and  has 
experienced  nocturnal  emissions  with  greater  or  less  frequency.  Morning 
erections  are  strong  and  vigorous,  and  apparenth^  perfectly  normal.  Sexual 
desire  is  felt  and  may  be  present  in  an  exaggerated  form.  When  such  a 
patient  attempts  intercourse,  erection  either  does  not  occur  at  all  or  takes 
place  in  a  spiritless  way  that  is  not  at  all  encouraging  to  his  mind.  When 
he  reflects  that  he  has  masturbated,  and  that  he  has  experienced  an  occa- 
sional nocturnal  emission,  with  perhaps  other  little  symptoms  that  coincide 
with  the  description  of  spermatorrhea  outlined  in  some  quack  treatise  or 
other,  he  becomes  completely  demoralized.  So  careful  do  these  patients 
study. quack  literature,  and  so  firmly  convinced  of  their  impotency  do  they 
become,  that  it  is  often  absolutely  impossible  to  gain  their  confidence  or  to 
benefit  them  in  any  way  whatever.  A  symptom  that  greatly  depresses  the 
patient's  mind  is  the  escape  of  prostatic  fluid  and  urethral  mucus  during 
prolonged  and  vigorous  erection. 

An  effort  should  be  made  to  obtain  the  fullest  confidence  of  such  indi- 
viduals, and  they  should  be  given  instruction  in  the  rudiments  of  sexual 
physiology.  In  the  majority  of  cases  they  may  be  reasoned  out  of  their  per- 
verted and  pernicious  notions  regarding  their  physical  condition.  Many 
times  we  are  compelled  to  be  somewhat  disingenuous  in  our  management  of 
the  case,  for,  the  patient's  confidence  once  gained,  some  comparatively 
trivial  local  or  general  measure  may  cure  the  case,  providing  the  individual 
believes  in  the  potency  of  the  treatment.  Above  all,  the  patient  should  be 
assured  that  his  sexual  apparatus  is  in  an  exceptionally  strong  and  healthy 
condition.  Marriage  should  be  recommended  where  practicable.  Eegard- 
ing  this  point,  however,  marriage  should  never  be  advised  unless  the  occur- 
rence of  strong  and  vigorous  erections  proves  copulation  to  be  possible. 
Even  under  these  circumstances,  an  occasional  unfavorable  result  will  ensue, 
because  of  persistent  psychic  inhibition  of  erectile  power  at  the  time  copula- 
tion is  essayed.  In  cases  dependent  upon  moral  or  mental  causes  prevailing 
when  copulation  is  attempted,  removal  of  the  circumstances  that  produce 
mental  depression  is,  of  course,  necessary.    The  elements  of  sexual  indifEer- 


TREATMENT    OF    IMPOTENCE.  587 

ence  due  to  mental  worry,  nervous  shock,  fear,  excessive  passion,  or  disgust 
for  the  individual  with  whom  intercourse  is  attempted  may  be  amenable  to 
correction. 

In  those  cases  of  married  men  in  which  lack  of  affinity  is  the  principal 
cause  of  impotence,  medical  measures  are  apt  to  be  unsuccessful,  although 
some  form  of  local  stimulation  of  the  sexual  organs  may  possibly  be  effi- 
cacious. The  divorce-court  is,  however,  a  better  and  more  logical  remedy 
if  the  circumstances  imperatively  demand  a  cure. 

In  many  instances  of  purely  nervous  impotence  irritability  of  the  pro- 
static urethra  exists.  This  may  be  removed  in  the  majority  of  instances  by 
the  occasional  passage  of  a  cold  steel  sound.  If  the  case  be  obstinate, 
astringent  applications  may  be  made  by  means  of  the  cupped  sound  or  deep 
urethral  syringe.  The  prostate  or  seminal  vesicles  are  sometimes  congested 
or  chronically  inflamed.  Massage  of  these  parts  relieves  this  condition. 
The  psychrophor  or  cooling  sound  is  sometimes  serviceable. 

In  cases  of  premature  ejaculation  success  may  often  be  attained  by  a 
second  attempt  at  copulation.  The  patient  should  be  advised  to  avoid  ex- 
citement during  intercourse.  He  may  very  often  succeed  in  delaying  or- 
gasm by  thinking  of  something  else  beside  sexual  intercourse  at  the  time 
of  its  performance.  Patients  who  are  apprehensive  of  failure  should  be 
advised  to  refrain  from  intercourse  during  the  night,  and  to  attempt  it  only 
in  the  early  hours  of  the  morning. 

In  some  instances  the  glans  penis  is  excessively  sensitive  as  a  conse- 
quence of  a  redundant  or  phimosed  prepuce.  Under  such  circumstances 
circumcision  will  usually  effect  a  cure.  Bathing  of  the  glans  in  a  solution 
of  alcohol  and  tannin  is  an  excellent  plan  to  remove  hyperesthesia. 

It  is  well  for  newly-married  men  affected  with  nervous  impotence  to 
confide  in  their  wives  and  explain  their  temporary  debility.  The  patient 
should  be  informed  that  soonor  or  later  he  will  have  a  vigorous  erection — 
as  soon,  at  least,  as  the  novelty  of  the  situation  has  worn  off  and  his  timidity 
has  been  allayed.  He  should  be  instructed  to  immediately  take  advantage 
of  the  situation,  when  an  erection  does  occur,  and  perform  the  marital  act. 

Measures  of  a  general  and  hygienic  character  are  requisite,  especially 
in  the  management  of  cases  in  which  actual  structural  disease  does  not  exist. 
These  general  measures  involve  proper  exercise,  diet,  baths,  proper  hours 
of  sleep,  temperance,  or,  better,  total  abstinence  in  the  matter  of  alcoholics 
and  tobacco,  and  freedom  from  care  and  worry  so  far  as  possible.  Such 
measures  apply  also  to  the  treatment  of  spermatorrhea,  a  condition  with 
which  impotence  is  very  often  associated. 

Cases  in  which  impotence  is  due  to  an  exhausted  condition  of  the  sex- 
ual apparatus  and  incidentally  of  the  general  nervous  system,  with  in  some 
instances  impairment  of  nutrition,  primarily  require  complete  sexual  rest. 
Occasional  or  so-called  moderate  indulgence  is  not  to  be  thought  of  in  these 
cases.     Perfect  continence  must  be  insisted  upon  for  the  time  being,  the 


588  lilPOTEXCE    IX    THE    MALE. 

length  of  time  varying  with  the  grayity  of  the  case.  It  is  unfortunate  that 
the  majority  of  patients^  and  particularly  voluptuaries,  are  loath  to  accept 
such  advice,  believing,  as  they  do,  that  by  means  of  aphrodisiacs  their  virile 
powers  should  be  restored  without  interfering  with  the  indulgences  that  are 
responsible  for  their  condition. 

Hammond's  remarks  upon  this  point  are  certainly  judicious.  He 
says: — 

I  have  generally  found  that  in  those  cases  in  which  an  erection  sufficient  for 
intromission  does  not  take  place,  sexual  repose  for  about  a  year  is  necessary.  Again, 
the  age  of  the  patient  and  the  length  of  time  during  Avhich  the  condition  has  existed 
are  factors  to  be  considered  in  determining  the  question.  In  persons  over  forty,  and 
in  whom  the  condition  has  lasted  six  months,  no  attempt  should  be  made  for  even 
a  longer  period  than  a  year.  With  every  unsuccessful  effort,  even  though  no  emission 
occurs,  the  nervous  excitability  is  still  further  lessened,  and  the  morale  materially 
lowered.  Generally  in  these  extreme  cases  there  is  no  difficulty  in  securing  the 
requisite  quiescence.  The  patient  is  fully  aware  of  his  inability,  and  is  in  no  mood  to 
undertake  what  he  knows  will  result  in  failure.  It  sometimes  happens,  however,  that 
masturbation,  with  the  erection  almost  nil  and  the  orgasm  imperfect,  is  practiced, 
when  the  individual  finds  that  intercourse  is  impossible.  It  is  in  this  respect  that  the 
requirement  of  rest  must  be  strictly  enjoined. 

Cases  in  which  the  principal  trouble  consists  of  premature  ejaculation 
and  feeble  erection  unquestionabh^  require  rest  for  a  time;  but  the  patient 
is  apt  to  disregard  the  instructions  of  his  medical  adviser  because  still  re- 
taining a  certain  degree  of  potency  and  able  to  copulate  after  a  fashion — 
sufficiently  well,  at  least,  to  make  the  indulgence  pleasurable.  In  cases  of 
this  kind  the  patient  should  be  informed  that  it  is  absolutely  impossible  to 
benefit  his  condition  unless  he  will  consent  to  at  least  six  months'  con- 
tinence. 

The  moral  tone  and  mental  condition  of  the  patient  deserve  special 
consideration.  The  remarks  that  have  been  made  in  connection  with  the 
subject  of  masturbation  and  sexual  excess  are  pertinent  in  these  cases.  Ex- 
ercise, intellectual  occupation,  and  avoidance  of  all  sources  of  sexual  stimu- 
lation must  be  insisted  upon.  Where  practicable,  the  patient  should  be 
advised  to  take  a  change  of  scene;  in  short,  to  cease  associations  that  tend 
to  excite  his  sexual  passions.  Traveling — and  particularly  a  sea-vo3^age — is 
excellent  for  these  cases. 

Cold  shower-baths  or  plunge-baths  are  excellent  adjuvants  to  the  gen- 
eral treatment.  Delicate  patients  should  begin  by  a  course  of  sponge-bath- 
ing. Cold  sitz-baths  or  hot  and  cold  water  in  alternation  is  useful.  Whatever 
form  of  bath  be  selected,  it  should  be  followed  by  brisk  rubbing  with  a  towel 
or  flesh-brush.  Local  douches  with  hot  and  cold  water  alternately  are  very 
stimulating  to  the  parts.  The  Turkish  bath  taken  in  moderation  and  fol- 
lowed by  the  cold  plunge  constitutes  one  of  the  best  of  general  tonics. 

The  diet  requires  some  attention.  It  should  consist  of  an  abundance 
of  easity-digestible  and  nutritious  food,  a  preponderance  of  nitrogenous  ele- 


TEEATMEXT    OF    IMPOTEXCE    IX    THE    MALE.  589 

ments  being  essential.  The  yarious  preparations  of  malt  and  codliver-oil 
are  excellent  means  of  improving  nutrition.  An  abundance  of  good  rich, 
milk  and  cream  is  demanded.  Meats  should  be  eaten  rare  and  should  con- 
tain considerable  fat.  A  moderate  amount  of  stimulants  is  often  useful. 
Claret,  port,  sherry  of  good  quality,  or  Dublin  stout  may  be  taken  with  the 
meals.  The  patient  should  be  advised  to  sleep  upon  a  hard  mattress  with 
light  covering,  this  measure  being  particularly  essential  if  nocturnal  emis- 
sions are  a  feature  of  the  case. 

Certain  internal  remedies  are  useful.  Contrary  to  the  general  belief, 
however,  there  are  no  specifics  for  impotence — i.e.,  there  are  no  drugs  that 
can  be  depended  upon  to  so  stimulate  the  sexual  apparatus  as  to  immediately 
render  copulation  possible.  Nearly  if  not  quite  all  of  the  aphrodisiac  reme- 
dies that  are  apt  to  be  useful  in  impotency,  with  the  possible  exception  of 
cantharides,  act  rather  as  general  restorers  of  nervous  energy  than  by  a 
special  predilection  for,  and  stimulation  of,  the  sexual  apparatus.  Much 
of  the  reputation  of  various  drugs  depends  upon  the  moral  effect  of  their 
administration  in  cases  of  pseudo-impotence.  Nearly  all  the  celebrated 
nostrums  and  quack  remedies  recommended  as  specifics  for  impotence  have 
become  celebrated  through  their  influence  upon  the  minds  of  the  patients. 
An  individual  who  is  impotent  because  of  lack  of  confidence  in  his  virility 
is  likely  to  be  relieved  by  a  trituration  of  milk-sugar,  providing  he  has  con- 
fidence in  the  efficacy  of  the  placebo.  If  some  alleged  aphrodisiac  be  given, 
it  is  apt  to  acquire  an  undeserved  reputation  for  efficacy.  The  best  remedy 
for  a  lack  of  tone  in  the  generative  apparatus  is  probably  iron.  The  tincture 
of  the  chlorid  may  be  given  in  doses  of  from  15  to  20  drops  in  water,  three 
times  daily,  after  meals.  The  pyrophosphate  of  iron  is  perhaps  a  more 
eligible  preparation  and  equally  efficacious.  It  should  be  administered  in 
doses  of  from  5  to  10  grains  thrice  daily.  It  may  be  advantageously  com- 
bined with  strychnia. 

The  following  is  a  favorite  prescription  of  the  author's: — 

I^  Ferri  pyrophos 3ii S  ij. 

Strychnise  sulph gi"-  j- 

Syr.  glycyrr giv. 

M.     Sig. :    3j  three  times  a  day,  after  meals. 

Ferratin  and  peptomangan  are  both  excellent  ferruginous  preparations. 

Nux  vomica,  or  its  alkaloid,  strychnia,  has  an  excellent  reputation  in 
the  condition  under  consideration.  Phosphid  of  zinc  and  nux  vomica  may 
be  given  in  combination.     The  following  is  an  excellent  formula: — 

IJ  Zinci  phcsphidi gr.  v. 

Ext.  nucis  vomicae gr.  xx. 

M.     Ft.  pil.  Xo.  xl. 

Sig. :    One  three  times  a  day,  after  meals. 


590  IMPOTEXCE    IX    THE    MALE. 

Opium,  the  bromids,  ergot,  digitalis,  gelsemium,  and  alcoholics  all  have 
their  uses  in  nervous  impotence. 

Phosphorus  is  the  most  reliable  remedy  in  these  cases.  It  may  be  giren 
in  solution,  as  a  tincture,  in  combination  with  zinc  as  in  the  formula  just 
given,  or  in  its  pure  state. 

A  pill  composed  of  V30  grain  of  phosphorus  and  ^/^  grain  of  nux 
vomica  is  an  excellent  combination.  The  principal  objection  to  the  use  of 
phosphorus  is  the  offensive  eructations  and  gastric  disturbance  it  sometimes 
produces.  The  mineral  acids — such  as  dilute  phosphoric,  muriatic,  and 
nitric — are  all  of  service.  Hypodermic  injections  of  strychnia  are  often 
useful,  a  single  daily  injection  of  ^/g^  grain  of  the  sulphate  of  strychnia 
being  more  elticacious  than  much  larger  and  more  frequent  doses  taken  i^er 
orem. 

Cantharides  exhibits  a  more  marked  and  direct  immediate  action  upon 
the  generative  apparatus  than  any  other  aphrodisiac.  It  should  be  given 
cautiously,  however,  for  in  large  doses  it  may  produce  inflammation  of  the 
bladder  and,  coincidently,  severe  strangury.  So  severe  are  its  effects  in 
some  cases  that  obstinate  priapism  and  insatiable  sexual  desire  may  occur, 
perhaps  with  inflammation  and  sloughing  of  the  penis  and  vesical  mucosa. 
Deaths  from  the  drug  have  been  frequently  observed.  In  impotence  the 
tonic  effect  of  the  drug  should  be  aimed  at.  It  may  be  given  in  from  10 
to  15  drops  three  times  daily.  In  occasional  cases  a  gradual  and  cautious 
increase  of  the  dose  is  warrantable.  Thus,  10  to  15  drops  three  times  a  day 
may  be  given  to  commence  with,  the  dose  being  increased  1  drop  each  day 
until  slight  strangury  is  produced,  when  it  should  be  discontinued.  If  there 
has  been  no  beneflt  to  the  impotence  by  this  time,  further  administration  of 
the  drug  is  useless.  Damiana  is  a  much-vaunted  remedy  for  impotence 
that  is  useful  to  a  certain  degree.  The  dose  is  1  or  2  drams  of  the  fluid 
extract  three  or  four  times  daily.  Both  damiana  and  cantharides  will  be 
reverted  to  in  a  subsequent  chapter. 

Ergot  is  often  a  valuable  remedy  in  impotence,  particularly  in  those 
cases  in  which  there  seems  to  be  a  lack  of  tone  in  the  vascular  supply  of 
the  penis.  It  may  be  given  in  doses  of  10  to  20  drops,  three  or  four  times 
daily.  Certain  cases  of  impotence  have  been  attributed  to  a  lack  of  tone  in 
the  dorsal  vein  of  the  penis,  this  condition  resulting  in  too  rapid  removal 
of  the  blood  from  the  part  during  erection.  Injections  of  ergotin  in  the 
course  of  the  vein  and  ligation  of  the  vessel  have  been  recommended  for 
this  hypothetic  condition,  but,  inasmuch  as  it  is  probable  that  the  dorsal 
vein  of  the  penis  plays  only  a  small  part  in  the  phenomena  of  erection,  the 
logic  of  this  treatment  is  open  to  question.  The  author  has  performed  the 
operation  of  ligation  a  number  of  times,  and  has  observed  some  apparent 
benefit,  but  is  not  prepared  to  say  that  the  improvement  was  not  due  to  the 
psychic  effect  of  the  operation.  It  is  well  worth  trial,  however,  in  other- 
wise intractable  cases.     According  to  Bartholow,  jaborandi,  or  its  alkaloid. 


TEEATMENT    OF   IMPOTENCE    IN    THE    MALE.  591 

pilocarpin,  is  an  active  aphrodisiac,  being  indicated  in  cases  characterized 
by  debilit}^  He  claims  that  it  is  more  efficacious  than  any  other  agent. 
The  dose  should  be  30  minims  of  the  fluid  extract,  night  and  morning,  or 
from  ^/g  to  ^/s  grain  of  the  muriate  of  pilocarpin  thrice  daily.  Cimicifuga 
is  also  recommended  by  the  same  authority,  particularly  in  those  cases  of 
impotence  accompanied  by  spermatorrhea  of  long-standing,  with  excessive 
nervousness  and  anxiety  and  diminished  sexual  desire. 

In  cases  in  whjch  premature  ejaculation  from  sexual  hyperesthesia  and 
active  secretion  of  semen  are  noted,  regular  intercourse  with  moderate  fre- 
quency, and  the  administration  of  such  remedies  as  potassiimi  bromid, 
chloral-hydrate,  gelsemium,  and  ergot  will  usually  relieve  the  condition. 
Potassium  bromid  is  the  most  popular  sedative  for  sexual  hyperesthesia  or 
excessive  desire,  so  often  attended  by  partial  impotency.  Its  efficacy  has, 
however,  been  disputed  by  some  authors.  In  explaining  the  sources  of 
fallacy  of  those  who  dispute  the  anaphrodisiac  effects  of  the  bromids  Bar- 
tholow  speaks  as  follows^: — 

1.  The  physiologic  effects  of  potassium  bromid  are  not  very  decided,  and  are 
readily  modified  by  any  local  disturbance. 

2.  Its  therapeutic  action  is  still  more  decidedly  influenced  by  local  morbid 
processes. 

3.  It  is  indicated  where  a  sedative  to  the  nervous  system  is  required:  e.g.,  in 
insomnia,  too  great  reflex  excitability,  nervous  and  spasmodic  affections  of  the 
larynx  and  bronchi,  sexual  excitement,  and  irritable  states  of  the  sexual  organs. 

4.  It  will  be  effectual  in  the  foregoing  conditions,  in  proportion  to  the  degree 
in  which  structural  lesions  are  absent,  or,  in  other  words,  in  proportion  to  the  de- 
gree in  which  these  morbid  states  are  functional  rather  than  organic. 

5.  These  conclusions,  the  result  of  observation  and  experiment,  afford  us  a 
satisfactory  solution  of  the  cause  of  failure  in  the  use  of  the  bromid  of  potassium. 
Sexual  excitement  in  mania  is  due,  as  shown  by  Schroeder  von  der  Kolk,  to  structural 
alteration  in  the  medulla  oblongata,  the  center,  according  to  this  author,  of  the 
sexual  impulse.  The  bromid  of  potassium  can  have  no  influence  over  these  structural 
alterations,  and  hence  cannot  control  manifestations  of  sexual  excitement  depending 
upon  them.- 

The  local  and  general  application  of  electricit}^  in  its  various  forms  is 
very  useful  in  impotency.  It  is  especially  useful  in  the  form  of  the  general 
faradic  bath,  the  current  being  applied  while  the  patient  is  in  a  tub  of  hot 
water.  Its  application  should  be  followed  by  a  cold  shower-  or  sponge- 
bath,  and  the  application  of  static  electricity  to  the  spine,  particularly  over 
the  lumbo-sacral  region.  It  is  sometimes  beneficial  to  apply  the  latter  form 
of  electricity  to  the  perineum,  penis,  and  testes.  Hammond  claims  that  he 
has  succeeded  by  means  of  the  static  apparatus  in  restoring  sensibility  to 
the  glans  penis  and  adjacent  tissues  when  galvanism  and  faradism  had 
failed.     While  inclined  to  take  some  of  this  gentleman's  clinical  observa- 


"Treatment  of  Spermatorrhea,"  p.  101. 

A  deduction  that  by  no  means  folloAvs  Schroeder  von  der  Kolk's  observations. 


592  IMPOTEKCE    IN    THE    MALE. 

tions  cum  grano  sails,  the  application  of  the  static  current  in  this  manner 
seems  rational  enough.  The  stimulating  effect  of  static  electricity  upon 
the  nervous  system  is  something  remarkahle;  some  patients  say  that  it  acts 
like  a  glass  of  champagne. 

The  faradic  current  in  moderate  strength  is  a  powerful  stimulant  to 
the  sexual  organs.  The  ordinary  sponge  electrodes  may  be  used,  the  posi- 
tive pole  being  applied  to  the  lower  part  of  the  spine  and  the  negative  to 
the  penis  and  testes.  More  benefit,  however,  is  sometimes  to  be  derived  by 
applying  the  negative  electrode  to  the  genitals  and  the  positive  to  the  inner 
aspect  of  the  thighs.  A  wire  brush  electrode  may  be  used  instead  of  a 
sponge,  this  being  attached  to  the  negative  pole  and  passed  up  and  down 
the  spinal  column.  The  positive  pole  may  be  placed  first  upon  the  nucha 
and  afterward  upon  the  lower  portion  of  the  spine,  the  wire  brush  being 
passed  over  the  genitals.  More  or  less  pain  is  caused  if  the  current  be  at 
all  strong,  but  considerable  benefit  will  be  derived  from  its  use.  The  cir- 
culation and  nutrition  of  the  spinal  medulla  is  greatly  improved,  and  the 
vigor  of  the  sexual  nerves  is  necessarily  increased.     The  application  of  the 


Fig.  124. — Author's  insulated  prostatic  electrode. 

wire  brush  to  the  genitalia  is  especially  serviceable  in  cases  of  impotence 
that  appear  to  depend  chiefly  upon  anesthesia  of  the  nervous  supply  of  the 
glans  penis.  The  galvanic  current  is  often  useful,  either  alone  or  in  com- 
bination with  the  faradic  current  on  alternate  days. 

One  of  the  best  stimulants  for  the  sexual  organs  is  the  faradic  current 
applied  directly  to  the  prostate.  An  insulated  sound  or  bougie  is  attached 
to  the  negative  pole  of  the  faradic  battery  and  passed  down  to  the  prostatic 
urethra.  The  positive  electrode  may  be  applied  to  the  spine,  thighs,  hypo- 
gastrium,  or  genitals.  It  is  best  applied  by  means  of  a  large  flat  sponge 
electrode  to  the  lumbar  region.  The  prostate  may  be  faradized  by  a  rectal 
electrode  attached  to  the  negative  pole.  The  galvanic  current  may  be  used 
in  a  similar  manner.  In  cases  in  which  the  trouble  appears  to  depend  chiefly 
upon  hyperesthesia  of  the  prostatic  sinus  much  benefit  may  often  be  derived 
from  the  application  of  the  positive  pole  of  the  galvanic  battery  to  the  pro- 
static urethra.  A  local  electric  bath  may  be  given  by  suspending  the  penis 
and  testicles  in  a  receptacle  of  warm  water,  the  negative  electrode  being 
placed  therein,  and  the  positive  held  in  the  patient's  hand.     In  applying 


TEEATMENT    OF    IMPOTENCE    IN    THE    MALE.  593 

electricity  directl}'  to  the  prostate  care  should  be  taken  to  avoid  too  pow- 
erfirl  currents  and  too  long  continuance  of  their  application.  Inflamma- 
tion of  the  neck  of  the  bladder,  and  even  prostatitis,  are  possible  sequences 
of  carelessness  in  this  regard. 

In  the  milder  types  of  impotence  the  local  application  of  electricity  by 
the  insulated  sound  in  combination  with  the  general  measures  that  have 
been  suggested  will  rarely  fail  to  restore  the  vigor  of  the  sexual  apparatus, 
providing  the  patient  is  faithful  in  his  treatment  and  devotes  sufficient  time 
to  it.  It  is  not  well  to  make  promises  regarding  the  length  of  time  neces- 
sary, and  the  patient  should  be  told  that  the  period  necessar}^  for  treatment 
can  only  be  determined  by  the  progress  of  the  case,  some  cases  yielding  in 
a  short  time,  while  others  require  a  protracted  course  of  treatment. 

It  should  be  remembered  that  to  achieve  permanency  of  result  it  is 
necessary  for  the  patient  to  continue  treatment,  and  to  abstain  from  sexual 
indulgence  for  some  little  time  after  his  capacity  has  apparently  been  re- 
stored. 

In  cases  of  premature  ejaculation  and  failure  of  erection  due  to  ex- 
treme sensitiveness  of  the  glans  penis,  circumcision  is  usually  necessary,  as 
most  of  these  cases  are  affected  Avith  redundancy  and  phimosis.  The  daily 
application  of  cold  water  to  the  glans  is  an  excellent  adjuvant  to  circum- 
cision. The  application  of  electricity  by  the  galvanic  brush  is  a  very  valu- 
able method  of  treatment. 

The  application  of  stimulating  embrocations  to  the  penis  has  been  rec- 
ommended for  impotence.  As  a  general  rule,  they  are  worse  than  useless. 
Sinapisms,  however,  as  recommended  by  Eoubaud,  may  be  of  temporary 
service  in  some  instances.  The  irritation  produced  by  mustard  is  sufficient 
to  reflexly  excite  an  erection  in  the  majority  of  instances.  Care  should  be 
taken  not  to  prolong  the  application,  lest  serious  inflammation  result. 
Cases  of  impotence  secondary  to  cerebral  or  spinal  disease  should  not  be 
subjected  to  much  special  treatment.  All  therapeutic  efforts  should  be 
directed  to  the  cure  or  improvement  of  the  primary  condition.  As  improve- 
ment of  the  condition  of  the  brain  and  cord  occurs,  a  corresponding  im- 
provement in  sexual  vigor  is  noted.  Some  remedies  for  impotence  are  in- 
jurious in  cases  dependent  upon  spinal  disease.  For  example,  spinal  ex- 
citants, such  as  phosphorus  and  strychnia,  should  not  be  given  in  locomotor 
ataxia,  as  they  are  liable  to  aggravate  the  organic  disease,  and  will  in  nowise 
benefit  the  impotence.  In  some  extreme  cases  of  sexual  hyperesthesia,  the 
application  of  silver  nitrate  to  the  deep  urethra  by  means  of  the  deep  ure- 
thral syringe  is  of  benefit. 

Most  of  the  deformities  of  the  sexual  apparatus  that  produce  impo- 
tence are  not  amenable  to  treatment.  Diagonal  section  of  the  roof  of  the 
contracted  urethra  may  benefit  some  cases  of  curvature  of  the  penis.  Epi- 
spadias, hypospadias,  and  certain  tumors  of  the  penis,  scrotum,  and  testicles 
are  amenable  to  treatment  by  the  knife. 


594  IMPOTEJs'CE   IN   THE    MALE. 

As  a  temporary  expedient  and  in  psychic  impotence^,  the  application 
of  very  hot  water  to  the  penis  and  testes  just  prior  to  copulation  is  often 
efficacious. 

The  cases  of  impotency  that  are  most  trying  to  the  physician  are  those 
met  with  in  individuals  at  ahout  middle  age  who  have  for  many  years  in- 
dulged ezcessively  in  sexual  intercourse.  Patients  of  this  sort  consult  the 
physician  in  the  hope  of  receiving  a  remedy  that  will  enahle  them  to  go 
on  with  their  excesses,  and,  as  a  rule,  they  do  not  attribute  their  condition 
to  its  true  cause.  It  is  hard  to  convince  such  patients  that  they  are  paying 
for  their  early  indulgence,  and  that  they  ought  not  to  expect  to  perform 
the  sexual  act  so  often  and  so  indiscriminately  as  when  they  were  young. 
Such  an  opinion  seldom  satisfies  them.  The  physician  is  consulted  by  many 
middle-aged  roues  who  complain  of  real  or  imaginary  sexual  exhaustion, 
spermatorrhea,  premature  old  age,  etc.,  and  these  cases  are  certainly  difficult 
to  manage.  If  the  patient  cannot  be  made  to  understand  the  physiologic 
conditions  involved  in  his  case,  and  the  importance  of  resting  sexually  in 
order  that  the  organs  involved  may  recuperate  their  exhausted  vitality,  very 
little  success  can  be  obtained  by  treatment.  There  is  a  vulgar  notion  among 
the  laity  to  the  effect  that  a  man  is  capable  of  just  so  many  acts  of  sexual 
indulgence  during  his  life-time,  and  that  he  may  either  distribute  these  acts 
at  proper  intervals  throughout  a  great  number  of  years  or  may  perform  them 
within  a  few  years  early  in  life.  There  is  much  of  truth  in  this,  for  it  is  a 
cardinal  rule  that  overexcitement  of  any  function  will  cause  loss  of  power. 
The  man  that  copulates  with  moderation  is  the  one  best  fitted  for  procrea- 
tion, because  he  is,  from  a  sexual  point  of  view,  the  most  energetic.  It  is  a 
well-known  fact  that  the  male  population  of  the  Orient  become  impotent  at 
a  very  early  age,  earlier  than  any  other  race  of  men,  on  account  of  free  in- 
dulgence of  their  sexual  appetites.  For  that  matter,  among  all  nations  men 
and  women  alike  suffer  from  premature  old  age  when  excessive  sexual  in- 
dulgence is  conjoined  with  a  life  of  indolence  and  ease.  The  man  who  in- 
dulges in  sexual  intercourse  most  frequently  in  his  youth  is  the  one  who  is 
most  likely  to  become  impotent  or  sterile  when  he  reaches  middle  age.  It 
is  said  that  quite  a  proportion  of  Oriental  males  become  impotent  at  the  age 
of  from  30  to  40  years. 

Moderation  in  sexual  intercourse  is  not  only  conducive  to  prolonged 
virility,  but  to  longevity.  It  is  certain  that  many  cases  of  neurasthenia  in 
both  male  and  female  are  due  to  sexual  excess. 

The  treatment  of  the  class  of  cases  under  consideration  depends  for 
its  success  mainly  upon  careful  instruction  of  the  patient  in  sexual  phys- 
iology. The  cause  of  his  disability  should  be  explained  to  him,  and  he 
should  be  assured  that  the  only  hope  of  restoration  of  virility  and  of  its 
perpetuation  lies  in  complete  rest  of  the  sexual  function  for  a  prolonged 
period,  with  moderate  indulgence  for  the  rest  of  his  life,  after  his  capacity 
has  returned.    In  conjunction  with  these  moral  means  for  restoration,  the 


STERILITY   AND    IMPOTENCE    IN    THE    FEMALE.  595 

remedies  and  local  measures  already  recommended  may  be  employed  as  the 
case  demands. 

Where  imjDotence  depends  upon  one  or  more  of  the  organic  conditions 
enumerated  in  connection  with  etiology,  the  cause  should  be  dealt  with  upon 
its  surgical  merits. 

AsPEEMiA. — The  term  "aspermism/'  or  aspermia,  has  been  applied  to 
some  cases  in  which,  although  erections  are  normal  and  copulation  is  per- 
formed with  facility,  there  is  no  ejaculation  of  semen.  There  may  or  may 
not  be  sexual  desire.  A  peculiar  feature  of  these  cases  is  that  the  patient, 
although  unable  to  have  an  emission  during  normal  intercourse,  invariably 
acknowledges  the  occurrence  of  voluptuous  dreams  attended  by  pleasur- 
able sensations  and  emission  of  semen.  On  examination  the  urethra  will 
be  found  to  possess  the  usual  amount  of  sensitiveness  in  all  parts,  excepting 
the  prostatic  sinus,  where  there  is  apparently  complete  anesthesia. 

The  author  has  observed  several  cases  in  which  aspermism  was  the 
foundation  of  impotence  and  sterility.  One  of  these  is  of  particular  in- 
terest:— 

Case. — A  healthy  man,  35  years  of  age,  who  had  never  had  any  ailment  or  in- 
jury, sought  advice  regarding  failure  of  emission.  The  patient  stated  that  he  had 
been  sexually  normal  until  within  a  year,  since  which  time  he  had  found  it  impossible 
to  have  either  orgasm  or  emission.  Sexual  desire  was  normal,  and  erections  perfect, 
but  no  amount  of  duration  of  effort  in  copulation  was  sufficient  to  bring  about  an 
orgasm.  Sexual  intercourse  had  never  been  indulged  in  to  any  great  extent,  even  be- 
lore  any  abnormality  was  noticeable.  Erotic  dreams  and  nocturnal  emissions  were 
quite  troublesome.  This  case  finally  yielded  to  faradism  of  the  prostatic  urethra.  The 
treatment  was  directed  to  the  relief  of  the  evident  anesthesia  of  this  part  that  was 
apparently  at  the  bottom  of  the  difficulty. 

Eoubaud  advanced  the  theory  that  aspermia  depends  upon  spasmodic 
contraction  of  the  muscular  fibers  about  the  mouths  of  the  ejaculatory 
ducts,  preventing  the  escape  of  the  semen  into  the  prostatic  sinus.  This 
view  is  hardly  in  accordance  with  the  physiology  of  the  part.  Keyes  says, 
anent  this  point: — 

Were  there  desire  and  pleasure,  prostatic  mucus  would  be  secreted  in  excess 
and  would  be  thrown  out  by  ejaculation,  while  the  semen  proper  would  collect  and 
distend  the  seminal  vesicles  and  ducts  below  th6  ejaculatory  orifices,  and  would 
escape  and  fiow  away  from  the  meatus  with  the  relaxation  of  spasm  brought  about 
by  the  fatigue  following  prolonged  sexual  intercourse,  but  this  is  not  the  case;  the 
fault  is  evidently  in  the  neiwes.  There  is  no  pleasurable  sensation,  no  call  for 
secretion  of  prostatic  mucus,  nor  for  a  supply  of  spermatic  fluid.  There  is  anesthesia 
of  the  prostatic  sinus,  and,  although  the  power  of  having  an  orgasm  and  ejaculation 
remains,  as  proved  by  dreams,  yet  there  is  some  connecting-link  missing  in  the  chain 
which  transforms  friction  of  the  glans  into  pleasure  at  the  prostate,  and  finally  into 
secretion  in  the  testicle. 

There  is  probably  not  only  anesthesia  of  the  floor  of  the  prostatic  ure- 
thra, but  a  lack  of  the  special  sensibility  of  the  nerves  of  the  glans  penis 


596  STEEILITT   AND    IMPOTENCE    IN"   THE    FEMALE. 

that  is  normally  acquired  during  erection.  It  is  possible,  too,  that,  although 
the  nerves  of  the  prostatic  sinus  are  normally  sensitive,  the  nerves  of  the 
glans  fail  to  appreciate  and  transmit  pleasurable  sensations.  The  function 
of  the  latter  nerves  is  perhaps  inhibited  by  the  consciousness  of  the  patient 
of  the  lack  of  sensibility  in  the  glans.  During  sleep  inhibition  does  not 
occur,  and  the  subconscious  memory  of  normal  copulation,  of  which  the 
patient  was  once  capable,  is  sufficient  to  impart  a  pleasurable  sensation  and 
reflexly  produce  an  orgasm. 

The  treatment  of  this  condition  is  generally  very  unsatisfactory.  Kou- 
baud  reports  a  case  in  which  blistering  the  perineum,  with  subsequent  ap- 
plication of  powdered  morphin,  produced  a  cure.  He  recommends  anti- 
spasmodics, in  accordance  with  his  theory  of  the  pathology  of  the  disease. 
Electricity  in  the  form  of  the  static  and  faradic  currents  applied  to  the  spine 
and  genitalia  would  appear  to  be  the  most  rational  form  of  treatment,  and 
has  been  moderately  successful  in  the  author's  hands. 

STEEILITY   AND    IMPOTENCE    IN    THE    FEMALE. 

An  exhaustive  discussion  of  sterility  and  impotence  in  women  would 
be  out  of  place  in  this  work.  It  belongs  more  properly  to  treatises  upon 
gynecology.  A  few  general  remarks,  however,  may  be  of  especial  service 
when  coming  in  juxtaposition  with  the  discussion  of  sterility  in  the  male. 

Statistics  show  that  about  one  in  eight  marriages  are  unproductive. 
As  already  seen,  a  portion  of  the  responsibility  for  sterility  must  be  borne 
by  the  male.    Most  of  it,  however.  Justly  falls  upon  the  female. 

Etiology. — The  causes  of  sterility  in  the  female  are  very  numerous, 
but  only  the  principal  ones  will  be  given  here.    These  are  as  follow: — 

1.  Inability  to  receive  the  semen.     (Impotence  from  various  causes.) 

2.  Inherent  or  acquired  resistancy  to  impregnation. 

3.  Failure  to  ovulate. 

4.  Inability  to  develop  the  ovum  after  fecundation. 

The  female  most  often  fails  to  receive  the  semen  from  default  upon 
her  own  part.  Various  local  conditions  may  prevent  her  from  having  coitus. 
These  conditions  comprise  such  congenital  or  acquired  malformations  Dr 
imperfections  of  development  as  prevent  penile  intromission.  In  these  rare 
cases  the  female  is  impotent  as  well  as  sterile.  Impotence  in  the  female  may 
be  due  to  incapacity  for  the  conlplete  performance  of  the  sexual  act.  She 
may,  however,  be  none  the  less  capable  both  of  insemination  and  impregna- 
tion. Frigidity — i.e.,  absence  of  sexual  desire  or  aversion  to  its  performance 
— and  absence  of  orgasm  constitute  one  variety  of  female  impotence.  Many 
women  never  experience  the  slightest  degree  of  voluptuous  excitement  dur- 
ing cohabitation,  yet  they  are  fruitful  and  bear  children.  It  has  been  held 
that  the  erectile  structures  of  the  genital  organs  become  turgid  even  in 
this  class  of  cases,  Just  as  it  occurs  in  the  male,  without  orgasm;  but  this 
is  doubtful.     Orgasm  is  necessary  to  the  normal  performance  of  the  sexual 


ETIOLOGY    OF    STERILITY   AND    IMPOTENCE    IN    THE    FEMALE.  597 

act  in  the  female  as  well  as  in  the  male,  and,  while  conception  may  occur 
without  it,,  it  is  the  exception  rather  than  the  rule,  be  the  orgasm  ever  so 
slight.  The  orgasm  in  the  female  must  subserve  some  physiologic  purpose, 
which  purpose  must  be  the  correlative  of  the  orgasm  in  the  male.  The  male 
orgasm  being  of  an  expulsive  character,  it  follows  that  the  female  orgasm 
must  be  for  the  purpose  of  furthering  the  reception  of  the  semen. 

Competent  observers  have  described  the  peculiar  behavior  of  the  uterus 
during  orgasm.  The  organ  appears  to  assume  a  more  perpendicular  posi- 
tion, and  sinks  lower  in  the  pelvis;  the  os  uteri  becomes  softer;  the  labia 
of  the  uterus  project  and  retract  alternately  in  such  a  manner  as  to  produce 
a  "suction"  effect.  These  phenomena  are  accompanied  by  the  emission  of 
a  clear,  sticky  mucus.  Granting  the  occurrence  of  these  phenomena  in  the 
cases  observed,  they  probably  occur  in  all  cases  where  there  is  a  normal 
orgasm.  They  probably  also  occur  to  a  greater  or  less  degree  in  all  females 
to  whom  sexual  congress  is  in  any  degree  pleasurable. 

Acton^  states  that  it  is  his  belief  that  the  majority  of  women  do  not 
experience  sexual  desire.     He  expresses  his  opinion  as  follows: — 

I  should  say  that  the  majority  of  women  (happily  for  society)  are  not  very 
much  troubled  with  sexual  feeling  of  any  kind.  What  men  are  habitually,  women 
are  only  exceptionally.  It  is  too  true,  I  admit,  as  the  divorce-courts  show,  that 
there  are  some  few  women  who  have  sexual  desires  so  strong  that  they  surpass  those 
of  men^  and  shock  public  feeling  by  their  consequences.  I  admit,  of  course,  the 
existence  of  sexual  excitement  terminating  even  in  nymphomania,  a  form  of  insanity 
that  those  accustomed  to  visit  lunatic  asylums  are  fully  conversant  with;  but,  with 
these  sad  exceptions,  there  can  be  no  doubt  that  sexual  feeling  in  the  female  is,  in 
the  majority  of  cases,  in  abeyance,  and  that  it  requires  positive  and  considerable 
excitement  to  arouse  it  at  all;  and  even  if  aroused  (which  in  many  instances  it  can 
never  be)  it  is  very  moderate  compared  with  that  of  the  male.  Many  persons,  and 
particularly  young  men,  form  their  ideas  of  women's  sensuous  feelings  from  what 
they  notice  early  in  life  among  loose,  or,  at  least,  low  and  vulgar  women.  There  is 
always  a  certain  number  of  females  who,  though  not  ostensibly  in  the  ranks  of  prosti- 
tutes, make  a  kind  of  trade  of  a  pretty  face.  They  are  fond  of  admiration,  they  like 
to  attract  the  attention  of  those  immediately  above  them.  Any  susceptible  boy  is 
easily  lead  to  believe,  whether  he  is  altogether  overcome  by  the  siren  or  not,  that  she, 
and  therefore  all  women,  must  have  at  least  as  strong  passions  as  himself.  Such 
women,  however,  give  a  very  false  idea  of  the  condition  of  female  sexual  feeling  in 
general.  Association  with  the  loose  women  of  the  London  streets  in  casinos  and 
other  immoral  haunts  (who,  if  they  have  not  sexual  feeling,  counterfeit  it  so  well  that 
the  novice  does  not  suspect  but  that  it  is  genuine)  seems  to  corroborate  such  an  im- 
pression, and,  as  I  have  stated,  it  is  from  these  erroneous  notions  that  so  many  un- 
manned men  think  that  the  marital  duties  they  will  have  to  undertake  are  beyond 
their  exhausted  strength,  and  for  this  reason  dread  and  avoid  marriage. 

Married  men,  medical  men,  or  married  women  themselves  would,  if  appealed  to, 
tell  a  very  different  tale,  and  vindicate  female  nature  from  the  vile  aspersions  cast  on 
it  by  the  abandoned  conduct  and  ungoverned  lusts  of  a  few  of  its  worst  examples. 


"The  Reproductive  Organs." 


598  STEEILITT   AND    IMPOTENCE    IN   THE    FEMALE. 

One  would  infer  from  Acton's  opinion  that  frigidit}^  is  the  normal 
and  physiologic  condition  of  the  average  woman.  While  ready  to  ac- 
cept the  statement  that  a  large  proportion  of  married  women  do  not  ex- 
perience sexual  desire,  the  author  does  not  believe  that  their  frigidity  is 
natviral,  but  holds  that  it  is  usually  due  to  mistreatment  on  the  part  of  the 
husband.  The  average  man  when  entering  upon  the  matrimonial  state 
gives  very  little  consideration  to  the  question  of  reciprocal  pleasure.  A 
virtuous  woman  necessarily  entertains  primarily  an  aversion'  for  sexual 
intercourse,  which  is  both  unesthetic  and  j)ainful  in  the  beginning,  and 
shrinks  from  it  with  becoming  modesty  and  physical  fear.  This  condition 
of  mind  is  by  no  means  improved  by  the  conduct  of  the  husband,  whose 
sole  idea  is  to  obtain  gratification,  irrespective  of  the  feelings  of  his  wife. 
For  a  time  he  is  perfectly  satisfied  with  his  matrimonial  relations  because 
of  their  novelty.  As  soon  as  this  wears  off,  however,  he  begins  to  recall  past 
experiences,  and  finds  fault  with  his  wife  for  her  lack  of  reciprocity.  By 
this  time,  unfortunately,  the  disgust  and  dread  of  the  marital  act  that  have 
been  inspired  by  the  brutality  of  the  husband  have  become  a  part  of  the 
woman's  very  existence,  and  she  usually  is  ever  afterward  absolutely  frigid. 
Having  become  satiated  and  disgusted  with  the  marriage-relation  the  hus- 
band is  apt  to  seek  elscAvhere  for  that  of  which  he  has  been  deprived  through 
his  own  mismanagement.  It  is  the  authors  opinion  that  in  most  instances 
of  frigidity  in  married  women  the  difficulty  would  have  been  obviated  and 
the  woman  would  have  become,  after  a  time,  perfectly  natural  in  respect 
to  the  sexual  function  if  the  husband  had  been  more  intelligent  and  con- 
siderate. It  is  by  no  means  the  ex-roue  alone  who  is  open  to  impeachment. 
The  inexperienced  man  is  often  more  at  fault,  through  ignorance,  than  the 
man  of  the  world  who,  perhaps,  has  done  more  than  his  share  in  educating 
women  in  sexual  love. 

The  old  adage  that  "familiarity  breeds  contempt"  is  an  excellent  one  as 
applied  to  matrimonial  infelicity.  The  divorce-courts  speak  volumes  with 
respect  to  inharmonious  sexual  relations  of  married  persons.  Ignorance  on 
the  part  of  the  woman,  brutality  or  ignorance  on  the  part  of  the  husband, 
and  perhaps  in  some  instances  excessive  indulgence  on  the  part  of  both— 
this  latter  bringing  satiety  and  physical  ills  in  its  train — are  responsible  for 
many  of  the  cases  that  are  brought  all  too  prominently  before  the  gaze  of  a 
patient  and  long-suffering  public. 

The  prevalent  custom  of  married  people  occupying  the  same  bed  is  the 
cause  of  more  instances  of  lack  of  harmony  in  sexual  matters,  and  incident- 
ally of  more  cases  of  sexual  excess,  than  anything  that  could  be  mentioned. 
It  certainly  tends  in  many  instances  to  lessen  the  mutual  respect  of  married 
couples,  and  to  pall  the  attractiveness  of  the  matrimonial  state.  If  married 
persons  occupied  separate  apartments  the  novelty  of  matrimony  would 
not  be  likely  to  wear  away,  and  our  divorce-courts  would  be  shorn  of  a  large 
proportion  of  their  cases. 


ETIOLOGY    OF    STEKILITY   AND    IMPOTENCE    IN    THE    EEMALE.  599 

Certain  mental  conditions  modify  the  sexual  passion  in  women.  It 
would  certainly  be  too  much  to  expect  a  refined  woman  to  be  possessed  of 
sufficient  animal  propensities  to  be  able  to  display  a  genuine  passion  with 
one  for  whom  she  has  an  aversion.  Once  let  a  woman — -however  passionate 
naturally — experience  a  feeling  of  disgust  or  hatred  for  her  husband,  and  it 
is  probable  that  she  could  not  exhibit  genuine  sexual  passion  if  she  would.  It 
is  certainly  true  that  some  women  are  extraordinarily  passionate  with  certain 
individuals,  while  absolutely  frigid  with  others.  This  is  well  illustrated  in 
the  case  of  the  average  prostitute,  whose  passion  in  her  strictly-business 
relations  is  more  often  assumed  than  real,  but  who  nevertheless  has  usually 
a  favorite  lover  who  certainly  has  no  cause  for  complaint.  Apropos  of  in- 
harmonious conjugal  relations  there  is  another  circumstance  that  often  ex- 
plains the  frigidity  exhibited  by  married  women.  Many  women  are  allowed 
to  become  mere  household  drudges,  and  become  so  exhausted  physically 
that  it  is  hardly  fair  for  their  husbands  to  expect  any  reciprocity  upon  their 
part.  The  tendency  of  hard  labor  to  divert  the  nervous  energies  from  the 
sexual  apparatus  has  already  been  expatiated  upon,  and  is  as  true  of  the 
female  as  the  male.  Many  women  are  restrained  from  the  exhibition  of  sex- 
ual passion  by  the  fear  of  conception,  their  apprehensions  being  augmented 
by  the  popular  and  to  a  certain  extent  justifiable  notion  that  the  danger  of 
impregnation  is  proportionate  to  the  amount  of  passion  exhibited  by  the 
woman. 

In  order  that  impregnation  may  occur,  it  is  necessary  that  living 
spermatozoa  should  come  in  contact  with  a  mature  healthy  ovule  at  some 
jjoint  above  the  uterine  cervico-corporeal  junction.  There  are  many  local 
conditions  that  prevent  this  meeting,  even  though  the  sexual  act  be  nor- 
mal. Uterine  displacements  and  flexions,  stenosis  of  the  cervix  or  either  os, 
uterine  or  intra-uterine  growths,  especially  those  located  in  or  about  the 
cervix;  and  stenosis  of  the  Fallopian  tubes,  ojDposing  both  the  doAvnward 
passage  of  the  ovule  and  the  upward  passage  of  the  spermatozoids,  are  all 
serious  obstacles  to  fecundation.  Conditions  resulting  in  painful  or  diffi- 
cult intercourse  necessarily  tend  to  prevent  the  ovule  and  spermatozoids 
meeting  under  physiologic  conditions.  Hypertrophy  of  the  cervix  with 
contracted  os,  pathologic  processes  wholly  or  partially  occluding  the  vagina, 
vaginismus  from  urethral  caruncle  or  other  cause,  tumors  of  the  vulva  or 
vagina,  and  imperforate  hymen  are  illustrations  of  such  conditions.  It 
must  be  understood  that,  while  women  under  such  circumstances  are  prac- 
tically sterile,  they  are  not  literally  so. 

The  author  recalls  a  very  peculiar  case  occurring  in  the  New  York 
Charity  Hospital  showing  that  sexual  congress  may  sometimes  be  carried  on 
by  the  female  under  extreme  difficulties: — ■ 

Case. — A  woman,  20  years  of  age,  with  complete  atresia  vaginae,  who,  strange 
to  say,  nevertheless  led  the  life  of  a  public  prostitute.  The  external  parts  were  per- 
fectly developed,  but  there  was  no  opening  whatever  corresponding  to  the  normal  situ- 


600  STERILITY   AND    IMPOTENCE    IN   THE   FEMALE. 

ation  of  the  vagina.  The  case  diflferedj  too^  from  ordinary  atresia,  inasmuch  as  there 
was  no  thickened  fibrous  cord  between  the  bladder  and  rectum  such  as  is  ordinarily 
met  with  in  occlusion  of  the  vagina,  and  which  represents  the  walls  of  the  canal 
that  have  become  fused  together.  AVhen  the  index  finger  of  each  hand  was  intro- 
duced into  the  bladder  and  rectum  respectively  nothing  could  be  felt  between  them 
but  the  walls  of  these  viscera.  Neither  uterus  nor  ovaries  could  be  detected.  How 
this  woman  copulated  is  a  mystery.  There  was  no  evidence  of  pederasty.  Whatever 
the  circumstances  may  have  been,  the  woman  certainly  was  not  aware  of  her  con- 
dition, but  supposed  that  she  had  been  performing  the  act  of  copulation  like  other 
women.  The  urethra  was  very  commodious,  and  it  is  possible  that  it  had  been 
utilized  as  a  sexual  way.     Such  cases  have  been  reported. 

The  conditions  that  interfere  with  the  normal  development  of  the  ovule 
are  a  terra  incognita  to  science.  It  is  jorobable  that  many  immature  ovules 
escape  prematurely  from  healthy  Graafian  follicles  from  one  cause- or  an- 
other. On  the  other  hand,  they  may  be  devitalized  by  disease.  In  either 
event  they  are  incapable  of  impregnation.  It  is  not  necessary  that  the 
ovaries  should  be  healthy,  however,  in  order  that  conception  may  occur.  ■ 
Women  with  extensively  diseased  ovaries  sometimes  conceive  and  bear 
healthy  children.  If  a  single  Graafian  follicle  be  healthy  and  there  is  noth- 
ing to  prevent  the  ovule  and  spermatozoa  coming  together,  conception 
may  occur.  On  the  other  hand,  a  healthy  mature  ovule  may  be  formed,  and 
many  healthy  ovules  be  discharged  from  the  ovary  from  time  to  time,  but 
fail  to  reach  the  uterine  cavity.  Infla^lmatory  affections  of  the  ovary  in- 
volving thickening  of  the  walls  of  the  Graafian  follicles  may  prevent  healthy 
ovules  from  leaving.  A  healthy  ovary  may  be  so  bound  down  by  surround- 
ing inflammation  that  the  ovules  cannot  escape.  Other  conditions  that  are 
fatal  to  the  physiologic  purpose  of  the  ovule  are  diseases  of  the  Fallopian 
tubes,  adhesions  of  the  fimbriae  to  the  ovary,  and  uterine  disease  producing 
closure  of  the  uterine  extremities  of  the  tubes. 

Granting  that  conception  has  occurred,  the  uterus  may  not  furnish  a 
suitable  nidus  for  the  reception,  attachment,  and  subsequent  development 
of  the  ovum. 

The  corporeal  endometrium  is  a  highly-organized  structure  and  often 
the  seat  of  pathologic  conditions.  Gestation  demands  that  it  be  healthy. 
Intra-uterine  disease  is  so  frequent,  however,  that  good  authorities  consider 
it  to  be  the  cause  of  sterility.  Women  thus  diseased  are  perfectly  capable  of 
conception;  but,  the  uterine  mucous  membrane  being  unfitted  for  the  at- 
tachment and  development  of  the  ovum,  they  are  practically  sterile. 

Endometritis,  the  most  common  of  intra-uterine  diseases,  bears  a  very 
important  relation  to  sterility.  It  not  only  interferes  with  gestation,  but 
the  dense,  glairy  discharge  it  produces  may,  by  plugging  the  cervical  canal, 
not  only  obstruct  the  entrance  of  spermatozoa,  but  by  its  toxicity  destroy 
or  inhibit  their  vitality.  Catarrhal  states  of  the  Fallopian  tube  often  result 
from  endometritis.  The  mucus  it  produces  may  so  coat  the  ovule  in  its 
downward  passage  that  the  spermatozoa  either  cannot  penetrate  it  or  else 
they  are  killed  by  its  toxic  properties. 


ETIOLOGY    OP    STEEILITY   AND    IMPOTENCE    IN    THE    FEMALE.  601 

There  are  numerous  other  etiologic  conditions,  some  of  which  are  symp- 
tomatica'lly  associated  with  those  already  mentioned.  In  408  cases  of  steril- 
ity studied  by  Kammerer  dysmenorrhea  was  observed  in  69;  menorrhagia 
and  metrorrhagia  in  57,  scanty  menstruation  in  41,  amenorrhea  in  2,  de- 
layed menstruation  in  8,  hysteria  in  16,  nervous  headache  in  3,  intercostal 
neuralgia  in  1.  Some  of  these  derangements  probably  had  no  causal  rela- 
tion to  the  sterility,  but  depended  on  the  same  conditions  as  the  latter. 

A  profuse  uterine  discharge,  of  whatever  kind,  may  wash  away  the 
ovule  before  or  after  impregnation.  Dysmenorrhea  is  undoubtedly  a  fre- 
quent cause  of  sterility.  In  the  membranous  form  sterility  is  a  matter  of 
course.  Dysmenorrhea  is  due  to  uterine  or  ovarian  disease  or  to  some  ob- 
struction to  the  free  escape  of  the  menses.  It  is  attended,  moreover,  by 
spasmodic  uterine  contractions  that  ma}^  persist  as  a  matter  of  habit,  and 
cause  the  expulsion  of  the  fecundated  ovum.  The  same  conditions  that 
produce  dysmenorrhea  also  prevent  the  spermatozoa  from  entering  the 
uterus  or  destroy  them  after  they  have  entered. 

Teeatment. — The  treatment  of  sterility  and  impotence  in  the  female 
belongs  to  the  domain  of  gynecology. 


CHAPTER  XXVI. 

Spermatokkhea. 

Few  subjects  in  medical  literature  have  been  treated  in  so  confusing 
a  manner  as  spermatorrhea  has  by  the  few  authors  who  have  deigned  to  give 
it  attention.  The  special  treatises  upon  the  subject  by  American  writers 
have  been  limited  in  number,  and  authors  in  general  have  well-nigh  ignored 
it.  So  obnoxious  has  the  subject  become  because  of  the  treatises  of  quacks 
and  impostors  that  reputable  physicians  have  shown  a  somewhat  excusable, 
but  illogical,  tendency  to  ignore  it  altogether.  It  is  a  remarkable  fact  that 
nearly  all  of  our  knowledge  of  the  subject  has  been  handed  down  from  the 
classic,  yet  overdrawn,  treatise  of  Lallemand:  a  work  that  has  been  ex- 
tensively quoted — both  the  original  and  the  English  translation.^  Excel- 
lent monographs  have,  however,  been  written  by  Milton,  Acton,  Howe, 
Hammond,  and  Bartholow,  the  latter  being  the  only  work  devoted  to  sper- 
matorrhea alone. 

It  is  unfortunate  that  the  reputable  general  practitioner  knows  so  little 
of  the  pathology  and  treatment  of  the  various  phases  of  aberration  of  the 
sexual  function  included  under  the  term  spermatorrhea.  As  a  rule,  the 
physician  takes  little  interest  in  the  subject,  probably  because  of  the  dis- 
repute into  which  it  has  been  brought  by  imposters  and  quacks;  and,  as  a 
consequence,  cases  of  this  kind  either  consult  the  charlatan  primarily  or 
are  driven  to  him  by  the  indifference  and  repugnance  exhibited  by  most 
reputable  physicians.  This  course  is  not  only  unjust  to  the  patient,  but 
imworthy  of  the  physician.  ISTo  function  of  the  body  is  more  intimately 
associated  with  the  welfare  and  happiness  of  the  human  race  than  that  of 
the  sexual  organs,  and  the  physician  is  no  more  justified  in  ignoring  its 
disturbances  or  refusing  to  treat  patients  suffering  from  them  than  in  the 
case  of  aberrations  of  structure  and  function  of  the  stomach,  liver,  or  kid- 
nej^s.  It  is  not  at  all  remarkable  that  spermatopathic  quacks  flourish  and 
wax  fat,  when  the  reputable  physician  by  his  neglect  of  a  plain  duty  to 
humanity  actually  drives  patients  into  their  toils.  It  is  unfortunately  true, 
moreover,  that  a  course  of  quackery  usually  produces  a  psychopathic  con- 
dition that  makes  the  patient  insusceptible  to  either  moral  persuasion  or 
medical  treatment,  should  he  finally  fall  into  the  hands  of  a  scientific  phy- 
sician who  is  competent  and  willing  to  advise  him. 

The  definition  of  spermatorrhea  has  given  rise  to  considerable  dis- 
cussion. The  majority  of  scientific  authorities  are  not  inclined  to  accept 
as  spermatorrhea  any  case  in  which  the  loss  of  semen  is  attended  by  erec- 
tion and  ejaculation.     Spermatorrhea  as  a  steady  flow  of  semen  does  not 


^  "Des  Pertes  Seminales  Involuntaires." 
(602) 


DEFIXITIOJsT    OF    SPEEMATOEEHEA.  603 

occur,  as  was  formerly  supposed.    The  seminal  loss  occurs  only  at  intervals 
and  under  special  conditions,  largely  mechanic  in  character. 

It  is  evident  that  spermatorrhea  was  recognized  by  the  ancients.  Thus, 
under  the  name  of  tabes  dorsalis  Hippocrates  describes  a  condition  that  is 
evidently   spermatorrhea,   as   follows: — 

This  disease  proceeds  from  the  spinal  cord.  It  is  frequently  met  with  among 
newly-married  people  and  libertines.  There  is  no  fever,  the  appetite  is  preserved,  but 
the  body  falls  away.  If  you  interrogate  the  patients,  they  will  tell  you  that  they 
feel  as  if  ants  were  crawling  down  along  the  spine.  In  making  water  or  going  to 
stool  they  pass  semen.  If  they  have  connection  the  congress  is  fruitless.  They  lose 
semen  in  bed,  whether  they  are  troubled  with  lascivious  dreams  or  not — they  lose  it 
on  horseback  or  in  walking.  To  epitomize,  they  find  their  breathing  difficult;  they 
fall  into  a  state  of  feebleness,  and  suffer  from  weight  in  the  head  and  a  singing  in 
the  ears.  If,  in  this  condition,  they  become  attacked  with  a  strong  fever,  they  die, 
with  cold  extremities. 

Acton  defines  the  disease  as  follows: — 

The  condition  or  ailment  which  we  characterize  as  spermatorrhea  is  a  state  of 
innervation  produced,  at  least  primarily,  by  the  loss  of  semen.  This  term,  I  admit,  has 
many  objections,  but  its  general  acceptance  would  render  it  inconvenient  to  alter  it  or 
to  employ  any  other.^ 

According  to  Bartholow,  the  term  spermatorrhea  should  be  restricted 
to  that  condition  in  which  involuntary  seminal  losses  occur  with  sufficient 
frequency  to  produce  a  definite  morbid  state. - 

Many  surgeons  regard  spermatorrhea  as  a  loss  of  semen  independently 
of  intercourse  or  masturbation:  i.e.,  involuntary  losses  of  all  kinds.  This 
interpretation  of  the  term  is  objectionable  because  of  its  comprehensiveness. 
It  necessarily  embraces  certain  conditions  in  which  involuntary  emission  of 
semen  occurs  as  a  perfectly  physiologic  phenomenon.  Some  authorities  will 
not  accept  as  spermatorrhea  any  case  in  which  the  discharge  from  the  ure- 
thra does  not  contain  spermatozoa,  as  demonstrated  by  microscopic  exam- 
ination. This  is  too  sweeping,  for  in  severe  cases  the  formation  of  the  semi- 
nal elements  may  finally  cease,  the  other  ingredients  of  the  seminal  secretion 
being  normal  or  nearly  so.  According  to.  the  author's  views,  the  term  sper- 
matorrhea should  be  applied  to  all  involuntary  seminal  discharges  that 
occur  without  orgasm. 

Seminal  losses  with  orgasm  are  most  conveniently  styled  pseudosper- 
matorrhea.  The  frequency  of  involuntary  losses  is  no  diagnostic  criterion, 
for,  while  robust  individuals  might  not  be  injured  by  two  or  three  dis- 
charges weekly,  delicate  patients  might  be  powerfully  affected  by  a  single 
weekly  emission.  In  estimating  the  importance  of  involuntary  emissions 
due  consideration  should  be  given  to  their  effect  upon  the  mind  of  the 
patient.     For  example,  a  patient  who  is  ignorant  of  sexual  physiology  and 

^  Acton,  op.  cit. 

^  "Spermatorrhea,"  Roberts  Bartholow. 


604  spePl:iIatoekhea. 

has  read  quack  literature  extensiyel}'  may  be  great!}'  depressed  and  worried 
by  an  emission  occurring  once  in  three  or  four  weeks,  while  another  less 
impressionable  individual,  who  knows  something  of  sexual  physiology  and 
has  not  had  his  mind  poisoned  by  fallacious  treatises,  will  bear  several 
emissions  weekly  without  apparent  ill  effects.  The  assertion  has  been  made 
that  nocturnal  emissions  are  no  more  injurious  in  their  effects  upon  the 
nervous  system  than  similarly  frequent  acts  of  normal  intercourse.  The 
author  does  not  believe  this  to  be  true.  ^Tiether  or  not  the  depression  re- 
sulting in  many  patients  from  an  occasional  emission  is  altogether  due  to 
the  moral  impression  produced  by  it  is  open  to  question,  but  certain  it  is 
that  intelligent  individuals  with  a  knowledge  of  sexual  physiology  claim 
that  such  emissions  are  much  more  enervating  than  normal  intercourse. 
They  confessedly  lack  the  physiologic  stimulation  of  normal  coitus. 

Etiology. — Lallemand^s  theory  of  the  pathology  of  spermatorrhea  im- 
plies the  existence  of  irritation  of  the  prostatic  urethra  and  seminal  ducts 
produced  by  various  influences.  He  admits  as  causes  of  the  disease  gouty 
and  rheumatic  conditions  of  the  sexual  apparatus,  gonorrhea  and  stricture, 
phimosis  and  accumulation  of  smegma  preputii,  masturbation  and  sexual  ex- 
cess, the  excessive  use  of  such  drugs  as  cantharides,  ergot  and  various  diu- 
retics, intemperance,  excessive  drinking  of  coffee  and  tea,  constipation,  irri- 
tation of  the  rectum  from  ascarides,  hemorrhoids,  fistula,  prolapsus  ani,  etc. 
He  claimed  that  in  severe  cases  he  had  demonstrated  upon  autopsy  inflamma- 
tion and  thickening,  with  sometimes  ulceration  of  the  vesiculse  seminales, 
ejaculatory  ducts,  and  prostatic  urethra.  Eecent  investigations  in  the 
pathology  of  the  seminal  vesicles  vindicate  Lallemand  to  a  certain  degree, 
but  such  conditions  probably  exist  only  in  rare  and  extreme  cases,  in  which 
the  spermatorrhea  is  not  causal,  but  secondary  and  symptomatic  or  even 
merely  coincidental. 

The  author  regards  the  essential  condition  in  spermatorrhea  as  hyper- 
esthesia and  exhaustion  of  the  general  nervous  supply  of  the  genitalia,  the 
special  areas  of  sexual  sensibility  in  the  genitalia,  the  afferent  nerves  of 
sexual  sensibility,  the  genito-spinal  center,  and  the  psychosexual  centers  in 
the  brain.  Hyperesthesia  of  the  caput  galUnaginis  is  a  most  important  ele- 
ment, both  in  true  and  false  spermatorrhea.  There  certainly  is  exhaustion 
and  irritability  of  the  nervous  system,  probably  occurring  in  the  following 
order:  1.  Of  the  nerve-supply  of  the  area  of  special  sexual  sensibility  on  the 
floor  of  the  prostatic  urethra.  2.  Of  the  afferent  nerves  of  sexual  sensibility. 
3.  Of  the  transmitting  fibers  of  the  spinal  cord.  4.  Of  the  receiving  centers 
of  the  brain.  The  final  result  is  a  greater  or  less  loss  of  general  nerve-tone; 
i.e.,  neurasthenia.  The  author  does  not  wish  to  imply  that  these  effects  are 
not  more  or  less  simultaneous,  but  that  the  serious  results  are  likely  to  be 
manifested  in  the  order  named.  Inasmuch  as  spermatorrhea  in  the  majority 
of  instances  is  the  result  of  sexual  excess  or  masturbation,  and,  moreover,  the 
effects  of  the  venereal  orgasm  being  expended  upon  the  nervous  system,  it 


ETIOLOGY    OF    SPEEMATOKKHEA.  605 

is  rational  to  infer  that  the  disease  when  fully  developed  is  essentially  a 
neurosis.  Bartholow  expresses  a  similar  view,  which  is  in  direct  opposition 
to  Lallemand.  According  to  Bartholow,  spermatorrhea  is  always  a  neurosis, 
and  any  structural  alterations  that  may  be  found  are  coincidental,  not 
causative.  He  asserts,  moreover,  that  Lallemand's  cases  in  which  organic 
changes  in  the  sexual  organs  were  claimed  as  the  essence  of  the  disease, 
were  selected  for  the  purpose  of  justifying  his  theory  and  practice. 

Sir  Henry  Thompson  claims  that  sexual  indulgence  cannot  have  the 
effect  of  producing  prostatitis — considered  to  be  so  important  in  the  etiology 
of  spermatorrhea  by  Lallemand— unless  gonorrhea  already  exists.  This 
dictum,  however,  the  author  cannot  accept. 

Peyer^  says: — 

Spermatorrhea  in  itself  is  not  a  disease,  as  little  as  fluor  albus  in  the  female  sex, 
but  is  only  a  symptom  of  various  pathologico-anatomic  conditions,  affecting  either 
locally  the  seminal  vesicles,  their  duets,  their  muscles,  and  surrounding  mucous 
membrane,  or  else  resulting  from  general  disturbances  of  the  body,  especially  in  the 
nervous  system.  The  several  nervous  disorders  that  accompany  spermatorrhea  are 
mostly  not  its  consequences,  but  co-ordinate  symptoms  of  a  pathologico-anatomic  con- 
dition:   the  original  cause  of  this  loss  of  semen. 

Granted  that  spermatorrhea  is  symptomatic  in  many  cases,  it  is  not 
necessarily  symptomatic  of  the  existing  perceptible  organic  local  conditions 
of  the  sexual  organs.  These  conditions  may  exist  coincidentally,  often  sec- 
ondarily, and  are  sometimes  produced  by  the  same  causes  as  are  responsible 
for  the  spermatorrhea,  the  essential  condition  underlying  the  spermatorrhea 
being  in  the  nervous  system.^ 

The  most  important  local  condition  associated  with  spermatorrhea  and 
pseudospermatorrhea  is  dilation  and  relaxation  of  the  orifices  of  the  ejacu- 
latory  ducts  as  a  consequence  of  frequent  overdistension.  The  vesiculge 
seminales  in  the  first  instance  become  so  hyperesthetic  that  they  are  intol- 
erant of  their  contents.  This  intolerance,  in  combination  with  hyperesthe- 
sia and  irritability  of  the  veru  montanum,  results  in  frequent  reflex  ex- 
pulsion of  the  semen.  Finally  the  orifices  of  the  ejaculatory  ducts  become 
so  dilated  that  the  semen  dribbles  away  at  will.  Such  cases,  however,  are 
extremely  rare.  It  is  not  the  loss  of  fluid  that  produces  debility  at  first, 
but  the  frequency  of  the  discharge  of  nervous  force,  which,  as  already  in- 
dicated in  connection  with  the  subject  of  masturbation,  is  quite  similar  to 
that  produced  by  an  epileptic  attack.  As  a  consequence  of  frequently- 
recurring  orgasm  produced  in  sexual  intercourse  or  by  masturbation,  the 
organs  become  so  weak  that  the  jolting  produced  by  horseback-riding,  or 
the  strain  incidental  to  gymnastic  exercise,  causes  an  emission.     So  hyper- 


^  Clinical  Microscopy. 

-  It  is  a  striking  fact  that  spermatorrhea  is  verv  rare  among  the  host  of  patients 
who  consult  the  surgeon  for  prostatic  and  deep-urethral  disease. 


606  SPEEMATOKEHEA. 

esthetic  are  the  sexual  centers  in  many  instances  that  the  mere  thought 
of  sexual  indulgence  produces  an  emission,  often  without  erection  or  sen- 
sation. 

Prolonged  sexual  excitement  without  gratification  is  one  of  the  fre- 
quent causes  of  the  simpler  forms  of  spermatorrhea.  Familiarity  with 
women,  in  combination  with  the  fostering  influences  of  immoral  literature 
and  associations,  keeps  up  a  constant  irritation  of  the  sexual  organs  that 
increases  their  sensibility  and  stimulates  the  secretion  of  semen.  If  the 
patient  does  not  masturbate  in  his  ignorance  or  viciousness,  Nature  is  quite 
likely  to  relieve  the  condition  of  turgescence  of  the  sexual  organs  by  an 
emission  during  sleep.  If  the  cause  be  not  removed,  the  seat  of  sexual  sen- 
sibility becomes  very  irritable,  the  organs  meanwhile  growing  weaker  until 
finally  involuntary  losses  become  extremely  frequent.  It  will  be  observed 
that  pseudospermatorrhea  may  merge  into  the  true  variety. 

Lallemand  divided  seminal  losses  into  nocturnal  and  diurnal,  the  noc- 
turnal losses  being  frequent,  physiologic,  and  due  to  sexual  excitement,  but 
becoming  pathologic  after  a  time  in  some  instances  because  of  their  abnor- 
mal frequency.  Some  patients,  he  claimed,  were  subject  to  both  diurnal 
and  nocturnal  escape  of  semen.  Diurnal  emissions,  according  to  this  au- 
thority, are  much  less  frequent  than  those  occurring  at  night,  although  they 
are  more  serious  and  more  rebellious  to  treatment.  They  occur  mostly 
Avithout  erection  or  ejaculation,  during  or  just  following  the  acts  of  def- 
ecation and  micturition.  The  results,  after  the  disease  is  well  established, 
were  described  by  Lallemand,  as  follows: — 

The  penis  becomes  relaxed,  the  erections  feeble.  The  corpora  cavernosa  either 
atrophy  or  their  vessels  lose  tonicity;  the  corpus  spongiosum  and  the  glans  penis  also 
shrink.  The  testes  undergo  a  certain  degree  of  atrophy;  the  superficial  veins  of  the 
penis  become  dilated  and  tortuous.  The  nervous  system  very  often  manifests  sympa- 
thetic disturbances  in  the  form  of  vertigo,  pains  along  the  course  of  the  principal 
nerves,  etc.  The  subjective  symptoms,  after  a  variable  longer  or  shorter  period,  be- 
come very  marked;  there  are  pains  in  the  lumbar  region,  aching  in  the  arms  and 
testes;  capricious  appetite  and  feeble  digestion;  the  bowels  become  deranged,  con- 
stipation alternating  with  diarrhea. 

Spermatorrhea  is  sometimes  a  symptom  of  nervous  disease,  particularly 
of  the  spinal  cord.  Thus,  it  is  occasionally  seen  in  locomotor  ataxia.  In 
conditions  of  this  kind  spermatorrhea  is  a  secondary  consideration  and 
should  be  regarded  as  such  with  respect  to  treatment.  In  the  majority  of 
instances  the  disease  is  associated  with  complete  or  partial  impotence.  The 
milder  types  of  pseudospermatorrhea  are  quite  apt  to  be  associated  with 
pseudo-impotence  because  of  the  effect  of  the  nocturnal  emissions  upon  the 
mind  rather  than  upon  the  virility  of  the  patient  per  se. 

Numerous  local  diseases  have  been  mistaken  for  spermatorrhea,  afford- 
ing abundant  material  upon  which  the  patient's  mental  distemper  is  fed 
by  the  quacks. 


VARIETIES    OF    SPERMATOEEHEA. 


607 


Besides  nocturnal  emissions,  the  organic  affections  and  functional  per- 
turbations that  are  most  often  erroneously  termed  spermatorrhea  are:  chronic 
urethral  catarrh,  stricture  with  accompanying  gleet,  prostatorrhea,  prema- 
ture ejaculation  of  semen,  vesical  catarrh,  and  phosphaturia. 

Yaeieties  of  Teue  Speematoeehea.— 1.  Diurnal  emissions  without 
erections  or  sexual  stimulation  of  any  kind. 

2.  Frequent  nocturnal  emissions  without  sensation  or  power:  i.e., 
escape  of  semen  with  neither  pleasurable  sensations,  dreams,  nor  erections. 

3.  Escape  of  semen  on  slight  provocation  without  erection,  or,  at  most, 
with  imperfect  erection. 

These  varieties  may  be  associated,  in  a  measure.    Usually  where  there 


Fig.  125. — Microscopic  appearance  of  normal  human  semen,  a,  Spermatozoids. 
6,  Columnar  epithelium,  c,  Bodies  inclosing  lecithin-granules,  d,  Squa- 
mous epithelium  from  the  uretlira.  d',  Testicle-cells,  e,  Amyloid  cor- 
puscles,    f,  Spermatic  crystals,     g,  Hyaline  globules. 


are  diurnal  losses  there  are  also  unconscious  losses  at  night.  All  varieties 
are  usually  associated  with  complete  or  partial  impotence.  Prostatorrhea 
may  co-exist. 

Bartholow  divides  the  disease  into  (1)  the  genital  form  and  (2)  the 
cerebral  form:   a  classification  that  appears  somewhat  impractical. 

Vaeieties  of  Pseudospeematoeehea. — 1.  Occasional  nocturnal  emis- 
sions, with  orgasm,  usually  with  dreams,  and  almost  always  accompanied  by 
erections.    There  are  usually  no  injurious  effects  except  perhaps  those  of  a 


608 


SPEKMATOEEHEA. 


mental  character.     In.  some  cases^  however,  the  various  disturbances  out- 
lined in  the  symptomatology  of  true  and  false  spermatorrhea  result. 

2.  Premature  ejaculation  in  coitus,  associated  with  pseudo-impotence 
("spermatospasm  os") . 

(a)  From  prostatic  hyperemia  and  hypersecretion. 

(&)  From  follicular  prostatitis. 

4.  Hypersecretion  of  the  urethral  and  prostatic  glands  during  erection. 

5.  The  appearance  of  spermatozoids  in  the  urine  after  erections,  etc. 

6.  Discharge  of  semen  during  a  very  difficult  stool. 

7.  Discharsfe  from  chronic  urethral  catarrh. 


3.  Prostatorrhea 


TABULATED  ETIOLOGY  OF   SPEEIIATOEEHEA  AND  PSEUDOSPEEMATOEEHEA. 

"  (a)  Defective   will-power   and   unstable   nervous 
equilibrium. 
(5)  Effeminate  and  defective  physique. 

(c)  Hereditary  inordinate  sexual  desire. 

(d)  Mental  influences,  exciting  sexual  desire;  e.g., 
erotic  novels,  pictures,  and  stories. 

(e)  Evil  associations  and  example. 
(/)  Freedom  from  restraint  in  associating  with 

the  opposite  sex. 
(g)  Excesses  in  eating  and  drinking. 


General  J 


Predisposing 
causes 


Local     <; 


Exciting  causes 


(a)  Precocious  development  of  the  sexual  organs 
and  function. 

(&)  Maldevelopment  of  sexual  organs,  such  as  hy- 
pospadias and  phimosis.  Imperfectly  de- 
veloped and  weak  testes. 

(c)  Acquired  conditions  of  disease,  such  as  phi- 

mosis, stricture,  urethritis,  prostatic  conges- 
tion and  inflammation,  cystitis,  stone  in  the 
bladder,  seminal  vesiculitis,  balanitis,  her- 
pes, and  constipation. 

(d)  Eeflex  irritation  from  hemorrhoids,  ascarides, 

fistula,  etc. 

(e)  Varicocele. 


(a)  Masturbation. 

(&)  Sexual  excesses. 

(c)  Cerebro-spinal  disease  and  injuries. 


Symptoms  of  Speematoeehea  and  Psetjdospeematoekhea. — The 
line  of  demarkation  between  true  and  false  spermatorrhea  is  determined  by 
the  occurrence  or  absence  of  erection  and  orgasm  at  the  time  the  emissions  of 


SYMPTOMS    OF    SPEEMATOEEHEA.  609 

semen  occur.  Aside  from  this  difference  the  symptoms  of  the  true  and 
false  varieties  are  the  same,  differing  in  degree  only.  It  is,  of  course,  un- 
derstood that  an  exception  is  made  of  those  rare  cases  in  which  seminal 
losses  are  the  result  of  cerebro-spinal  disease — as  sometimes  seen  in  locomotor 
ataxia. 

Local  Symptoms. — -A  sense  of  weight  and  dragging  in  the  testes  and 
spermatic  cords;  sensitiveness  and  perhaps  neuralgia  of  the  testes,  urethra, 
and  cords;  relative  smallness  and  softness  of  the  testes,  pendulous  scrotum, 
congestion  of  the  pampiniform  plexus, — often  amounting  to  varicocele, — 
dilation  of  the  superficial  veins  of  the  penis  and  relative  diminution  in  size 
of  the  organ,  the  veins  of  which  are  distinctly  enlarged,  coldness  and  loss  of 
sensibility  of  the  penis,  and,  most  important  of  all,  the  escape  of  semen  at 
stool  or  with  the  urine,  or  as  a  result  of  erotic  dreams  or  sexual  excitement. 
On  examination  the  entire  urethra,  prostate,  and,  especially,  the  prostatic 
urethra  are  almost  uniformly  very  sensitive.  Partial  or  complete  impotence 
is  usual.  It  is  to  be  remembered  that  none  of  the  foregoing  symptoms  are 
characteristic;  neither  are  they  of  importance,  so  far  as  spermatorrhea  is 
concerned,  unless  involuntary  seminal  discharges  without  orgasm  co-exist. 
The  semen  is  abnormally  constituted,  being  thin,  and  more  or  less  watery. 
It  is  often  scanty  in  amount.  The  spermatozoa  are  relatively  few  in  num- 
ber, inactive,  and  poorly  developed.  In  extreme  cases  spermatozoa  may  be 
absent:  azoospermia. 

General  Symptoms. — There  is  more  or  less  disturbance  of  the  sym- 
pathetic nervous  system,  as  evidenced  by  capricious  appetite,  impaired 
digestion,  constipation,  or  diarrhea.  Pain  in  the  back,  headache,  and  neu- 
ralgias in  various  situations,  gastralgia,  and  abdominal  pain  are  not  unusual. 
The  headache  is  usually  occipito-frontal,  and  sometimes  associated  with 
more  or  less  marked  vertigo  or  a  sense  of  cerebral  fullness.  The  skin  is 
usually  sallow  and  pale,  or  muddy.  Acne  is  plentiful  in  young  subjects. 
The  facial  expression  is  one  of  care  and  anxiety,  or  of  deep  melancholy. 
The  subject  is  morbidly  self-conscious  and  inclined  to  shun  companionship. 
Profound  mental  depression  with  failure  of  memory  and  loss  of  the  power 
of  concentration  are  usually  prominent  symptoms.  The  patient  acquires 
the  habit  of  introspection  and  becomes  extremely  hypochondriac.  His 
genius  for  the  invention  of  symptoms,  fostered  as  it  usually  is  by  reading 
quack  literature,  becomes  phenomenal.  Insanity  is  perhaps  rare,  but 
suicidal  mania  is  occasionally  seen.  Thoughts  of  suicide  are  a  choice  in- 
tellectual morsel  with  a  large  proportion  of  these  patients,  but  the  real 
suicidal  intent  is  generally  lacking.  Many  such  patients  come  to  regard 
thoughts  of  suicide  as  a  mild  sort  of  dissipation  which  perhaps  makes  their 
melancholy  more  tolerable.  The  knowledge  that  there  is  a  final  way  out  of 
their  troubles — although  they  are  not  in  the  least  inclined  to  take  advan- 
tage of  it — is  in  the  highest  degree  comforting  to  some  spermatorrheic  or 
spermatophobiac  patients. 


610  SPEEJIATOEEHEA. 

The  circulation  is  generally  feeble  in  spermatorrhea.  Coldness  of  the 
feet  and  hands  is  often  complained  of,  and  the  pulse  is  apt  to  be  irritable 
and  either  quick  and  feeble  or  irregular.  Lithemia  is  a  frequent  concomi- 
tant of  the  disease.  Bartholow  says  that  the  urine  is  "pale,  of  low  specific 
gravity,  and  loaded  with  urates."  Pale  urine  of  low  specific  gravit}^  and 
loaded  with  urates  is  something  of  an  anomaly.  Phosphaturia  and  oxaluria 
are  very  frequently  met  with  in  spermatorrhea,  oxaluria  being  especially  fre- 
quent. The  lumbar  pain  so  often  met  with  is  not  uncommonly  due  to 
oxaluria  rather  than  to  the  sexual  derangement  per  se. 

Many  spermatorrheics  complain  of  disturbed  or  failing  vision.  Blur- 
ring or  spots  before  the  eyes — muscce  volitantes — are  the  most  frequent 
sources  of  complaint. 

The  most  important  varieties  of  pseudospermatorrhea,  so  far  as  their 
liability  to  be  mistaken  for  true  spermatorrhea  is  concerned,  are  charac- 
terized b}^  the  escape  of  semen-like  fluid  from  the  urethra  (a)  at  stool, 
(&)  with  the  last  straining  effort  of  micturition,  or  (c)  during  or  after  sexual 
excitement,  either  with  or  without  erection.  Bartholow  remarks  upon  this 
point  as  follows: — 

After  every  erection  without  ejaculation  there  is  a  mucous  flow  from  the  urethra. 
A  mixture  of  this  with  the  semen  produces  the 'so-called  watery  semen.  The  same 
discharge  is  often  observed  after  urination  and  defecation.  It  alarms  the  patient 
because  he  believes  that  it  is  seminal.  These  are  the  cases  to  Avhich  M.  Lallemand 
applies  the  term  "diurnal  pollution."  If  a  proper  examination  of  this  fluid  be  made, 
it  will  be  found  not  to  contain  spermatozoa.  It  is  a  thick,  transparent  albuminous 
fluid,  alkaline  in  reaction.  The  presence  of  spermatozoa  is  essential  to  prove  the  exist- 
ence of  semen.  No  other  test  is  applicable  than  the  microscopic.  It  cannot  be  denied 
that  spennatozoa  may  be  found  in  the  urine  or  mucous  secretion  from  the  urethra, 
if  a  nocturnal  emission,  or  an  emission  produced  by  natural  or  unnatural  means,  has 
recently  occurred;  but  these  fluids  should  be  examined,  when  this  source  of  error  may 
be  eliminated. 

This  accords  with  the  views  of  Flint,  who  long  ago  said^: — 

In  most  of  these  eases  the  fluid  is  either  the  liquor  prostaticus  or  a  secretion 
from  the  vesiculse  seminales.  The  microscope  affords  the  only  mode  of  determining 
that  the  fluid  is  seminal.  Were  this  mode  of  examination  generally  adopted,  cases 
of  spermatorrhea  would  be  extremely  rare. 

Hassell,  in  one  of  the  early  editions  of  his  work  on  the  urine,  says^: — 

Care  must  be  taken  not  to  confound  the  discharge  of  urethral  gleet  with  seminal 
fluid;  the  distinction  is  easy,  since  the  former  is  distinguished  by  the  presence  of 
infusoria,  by  the  presence  of  scaly  epithelium,  and  by  the  escape's  being,  in  general, 
continuous.  Sometimes  the  gleety  discharge  occurs  only  after  sexual  excitement  and 
lasts  but  for  a  short  time,  Avhen,  of  course,  its  character  is  more  apt  to  be  mistaken. 
The  prostatic  fluid  might  also  be  mistaken  for  semen:  in  this  the  spermatozoa  would 
also  be  absent,  and,  in  addition,  the  microscope  would  reveal  in  it  the  presence  of  the 


^  "Practice  of  Medicine." 

-  "The  Urine  in  Health  and  Disease.' 


SYMPTOMS    OF    SPERMATOKRHEA. 


611 


Drostatic  cylinders,  and  perhaps,  also,  of  the  peculiar  lamellated  concretions  of  phos- 
3hate  of  lime,  which  are  found  in  the  prostate  in  such  numbers.  Like  the  mucus 
:rom  ordinary  gleet,  that  from  the  prostate  may  also  be  continuous,  but  more  fre- 
quently it  appears  only  after  A'iolent  efforts  of  defecation,  when  a  small  quantity  of 
natter  may  be  expressed,  forming  only  a  drop  or  two,  of  a  thick,  stringy,  and  trans- 
jarent  fluid,  which  appears  at  the  orifice  of  the  urethra. 

It  is  easy  to  mistake  the  discharge  of  chronic  urethral  catarrh  for 
;emeii.  This  mistake  does  not  often  occur;,  however,  for  the  experienced 
nan  with  past  gonorrheal  troubles  does  not  usually  attribute  his  discharge 
:o  any  but  the  real  cause.  A  moment's  reflection  is  sufficient  to  show  that 
:here  is  abundant  room  for  mistakes  in  the  microscopic  diagnosis  of  urethral 
iischarges.     The  prostatic,  urethral,  and  Cowper's  glands  are  prodigal  in 


Fig.   126. — Spermuria.     Last   drop   of  urine   expelled  in  a   case 
of  spermatorrhea. 

iecretion,  and  slight  stimuli  or  mechanic  pressure  are  often  sufficient  to 
;ause  the  secretion  to  appear  at  the  meatus.  Bladder-mucus  or  muco-pus, 
md  phosphatic  deposit  in  the  urine,  are  also  sources  of  error.  It  must  be 
■emembered,  however,  that  in  genuine  spermatorrhea  sexual  excitement 
md  mechanic  pressure  may  cause  true  seminal  discharge,  which  may  at 
mce  appear  at  the  meatus,  or  pass  backward  to  appear  later  in  the  urine. 
iiVhenever  true  semen  appears  at  the  meatus  without  orgasm,  the  author 
relieves  that  the  function  of  the  muscular  urethra  is  temporarily  inhibited, 
)r  overcome  by  prostatic  pressure,  or  else  orgasm  occurs,  but  is  too  feeble  to 
)e  perceptible  to  the  patient's  weakened  sensorium. 

Symptomatic  spermatorrhea  in  central  nervous  disease  requires  brief 


612  SPEEMATOEKHEA. 

special  consideration.  As  niight  be  inferred  from  the  fact  that  sexual  ex- 
cesses and  masturbation  bear  an  important  etiologic  relation  to  locomotor 
ataxia,  spermatorrhea  is  more  often  associated  with  that  form  of  nervous 
disease  than  with  any  other.  In  passing,  the  author  desires  to  express  the 
opinion  that,  notwithstanding  the  fact  that  sexual  abuses  are  often  a  very 
important  factor  in  tabetic  etiology,  it  is  very  doubtful  if  such  influences 
alone  ever  cause  tabes.  Primary  predisposition, — often  involving  heredit}'-, — 
syphilis,  alcoholism,  and  nervous  overstrain,  one  or  all,  are  likely  to  co- 
operate with  faulty  sexual  hygiene,  which  becomes,  therefore,  merely  a  con- 
tributory cause,  albeit  an  important  one. 

Sexual  phenomena  in  tabes  usually  develop  in  the  early  stage  of  the 
disease.  Meryon,  Trousseau,  Duchenne,  Topinard,  and,  later,  Bartholow 
are  a  few  of  the  prominent  writers  who  have  called  attention  to  these  symp- 
toms.    Topinard  speaks  as  follows^: — 

Four  symptoms  present  themselves:  spermatorrhea,  satyriasis,  anaphrodisia,  and 
impotence.  The  first  occurs  among  the  most  remote  antecedents  of  the  first  period  of 
tabes,  throughout  which  it  continues.  The  nocturnal  pollutions,  at  first  accompanied 
by  erections  and  a  sensation  of  pleasure,  at  last  become  passive.  After  the  sper- 
matorrhea, or  without  having  been  preceded  by  it,  there  occur,  after  some  months  or 
years,  progressive  diminution  of  desire,  difficulty  in  procuring  satisfaction,  and  at  last 
absolute  imjDotence. 

Topinard  mentions  a  case  of  ataxia  in  which  the  patient  was  tortured 
for  thirty  years  by  priapism  so  obstinate  as  to  yield  only  to  large  and  in- 
creasing doses  of  opium. 

Among  other  neuropathic  disorders  in  which  spermatorrhea  often  oc- 
curs as  a  symptom  may  be  mentioned  neurasthenia  from  various  causes; 
tumors  and  other  diseases  of  the  pons,  medulla,  and  especially  of  the  cere- 
bellum; inflammation,  tumors,  and  syphilis  of  the  spinal  cord:  epilepsy,  cer- 
tain phases  of  insanity,  and  diabetes  mellitus. 

AVith  reference  to  the  diagnosis  and  relative  importance  of  symptomatic 
spermatorrhea,  Bartholow  says-: — • 

In  all  cases  in  which  the  involuntaiy  loss  is  a  symptom  it  is  of  little  conse- 
quence from  the  therapeutic  point  of  view:  the  centric  lesion,  of  which  it  is  a  sign, 
is  the  point  of  importance  to  which  our  attention  should  be  directed. 

That  the  spermatorrhea  is  a .  symptom  merely  should  be  easily  determined  by 
reference  to  the  accompanying  lesions.  There  will  be  present  evidences  of  degenerative 
changes  in  the  great  vessels,  in  the  fundus  oculi,  in  the  organs  of  special  sense,  and  in 
cerebro- spinal  centers.  As  a  rule,  spermatorrhea  as  a  substantive  affection  occurs  in 
the  young,  in  men  at  the  most  vigorous  period  of  life,  and  is  a  result  of  the  abuse  of 
the  sexual  organs.  On  the  other  hand,  spermatorrhea  as  a  symptom  appears  after 
the  middle  period  of  life,  during  the  decline  of  sexual  activity,  and  coincidently  with 
symptoms  indicating  lesions  of  the  cerebro-spinal  apparatus.  When  spermatorrhea  is 
a  symptom,  the  important  centric  lesions  on  which  it  depends  soon  manifest  them- 


"De  I'Ataxie  Locomotrice,'"  etc. 
Op.  cit. 


SYMPTOMS  OF  SPEEMATOEEHEA.  613 

selves  by  other  and  more  characteristic  signs,  whereas  when  spermatorrhea  is  a  disease 
the  case  remains  in  very  much  the  same  state  for  months  or  even  years.  Attention  to 
these  points  can  hardly  fail  to  conduct  the  examination  to  a  correct  conclusion. 


Pseudospermatorrliea,  Avhile  really  of  slight  pathologic  importance,  is, 
because  of  its  relative  frequency,  of  greater  clinical  moment  than  the  genu- 
ine form.  The  psychic  effects  of  spermatophobia  are  so  numerous  and 
varied,  and  so  magnified  by  the  imagination  of  its  victims,  that  the  in- 
genuity and  breadth  of  mind  of  the  physician  are  often  sorely  taxed  in  the 
management  of  such  cases.  While  inexcusable,  it  is,  in  a  way,  hardly  re- 
markable that  most  physicians  are  content  with  a  laissez-faire  policy  in  deal- 
ing with  spermatophobiaes.  Conscious  that  the  patient  is  suffering  with 
ailments  which,  from  an  organic  stand-point,  are  maladies  imaginaires,  the 
medical  man  feels  justified  in  "pooh-poohing"  his  patient's  tale  of  woe 
which,  baseless  though  it  is,  is  yet  sufficiently  unutterable  to  the  sufferer. 
The  lack  of  an  organic  foundation  renders  the  symptoms  none  the  less 
prominent.  Pseudo-impotency  is  often  regarded  as  a  fitting  subject  for 
jest  on  the  physician's  part,  but,  to  the  sufferer,  the  absence  of  erection,  or 
the  presence  of  other  conditions  that  render  successful  copulation  impos- 
sible, is  terribly  real.  Each  and  every  symptom,  therefore,  merits  consid- 
eration— as  a  beginning  of  suggestive  therapy,  if  nothing  more. 

The  spermatophobiae  invariably  becomes  extremely  hypochondriac  and 
practices  introspection  with  a  zeal  that  is  worthy  of  a  better  cause.  The 
slightest  sensation  of  a  subjective  character,  which,  by  persons  of  a  normal 
psychic  condition;  would  either  be  ignored  or  attributed  to  some  rational 
cause,  is  attributed  by  the  sufferer  from  pseudospermatorrhea  to  seminal 
losses.  Should  he  perchance  discover  in  addition  to  an  occasional  emission 
a  little  cloudiness  of  the  urine,  or  a  slight  discharge  at  the  meatus  after 
micturition  or  during  a  difficult  stool,  his  worst  fears  are  confirmed  and  he 
believes  himself  a  victim  of  the  worst  imaginable  type  of  spermatorrhea. 
Should  he  have  any  remaining  doubts  as  to  the  diagnosis  they  are  dispelled 
by  the  first  chance  bit  of  quack  literature  that  he  peruses.  And  peruse 
quack  literature  he  will,  as  the  only  possible  source  of  enlightment  upon 
sexual  matters.  Eeliable  information — indeed,  the  simplest  physiologic 
truth — is  denied  him  because  of  the  hide-bound  condition  of  an  ultra- 
ethical  and,  if  the  truth  were  known,  often  essentially  hypocritic  profession. 
The  author  is  aware  that  the  foregoing  statement  has  a  decidedly  radical 
flavor,  but  he  has,  nevertheless,  no  hesitancy  in  expressing  the  view  that 
some  phases  of  so-called  medical  ethics  are  positively  sickening. 

The  symptomatology  constructed  by  spermatophobiaes  is  best  appre- 
ciated by  perusal  of  their  correspondence.  It  is  as  historians  of  their  own 
cases  that  these  patients  especially  distinguish  themselves.  All  experi- 
enced neurologists  and  andrologists  will  at  once  recognize  the  t^^De  shown  in 
the  following  letter  received  by  the  author: — 


614  SPEK^IATOEEHEA. 

My  dear  Doctor: 

You  will  doubtless  be  surprised  to  receive  a  letter  from  me  so  soon  after  the 
consultation  of  yesterday;  but^  on  reflection,  I  fear  that  I  gave  you  a  very  meager 
account  of  a  case  which  seems  to  me  much  more  serious  than  you  realize,  judging  from 
the  advice  you  gave  me  to  "stop  studying  my  symptoms  and  cultivate  a  spirit  of 
indifference  toward  my  numerous  sensations."  I  therefore  take  the  liberty  of  writing 
my  symptoms  more  in  detail:  — 

The  state  of  my  mind  is,  jjerhaps,  more  important  than  anything  else.  As  I  told 
you,  I  dread  getting  among  people,  no  matter  how  congenial  they  may  bej  but  I  did 
not  tell  you  the  chief  reason  for  my  aversion  to  society.  I  am  sure  that  my  appearance 
betrays  my  condition,  and  many  times  I  know  from  the  queer  way  in  Avhich  people 
look  at  me  while  talking  with  each  other  that  they  are  discussing  my  ailment. 
Imagine  my  feelings,  if  you  can.  Of  course,  my  confusion  settles  all  possible  doubt  in 
their  minds  as  to  the  correctness  of  their  conclusions.  I  am  positive,  also,  that  the 
horrible  odor  of  which  I  spoke  to  you  really  does  come  from  the  affected  parts,  and  is 
so  plain  that  he  who  runs  may  read.  At  the  times  when  I  detect  the  odor,  the  parts 
seem  bathed,  in  a  cold,  clammy  sweat,  though  the  skin  does  not  feel  \vet.  I  have  fre- 
quent spells  of  ringing  in  the  ears,  and  sometimes  snapping  sounds  with  some  pain 
that  must  be  in  my  ear-drums.  Just  before  meals  I  am  dizzy,  and  this  comes  on  just 
from  hearing  dinner  ahnounced.  I  notice  that  the  spots  before  my  eyes  come  only  in 
daylight  and  are  plainer  on  cloudy  days.  I  am  sure  my  hair  is  getting  very  thin  and 
it  seems  very  oily  at  times,  and  at  such  times  the  scalp  is  hot  and  tingling.  Almost 
always,  after  meals,  there  is  a  full  feeling  in  my  stomach  and  bowels,  and  my  breath 
seems  like  the  odor  of  tobacco,  though  I  do  not  use  it.  I  get  very  much  depressed  at 
times  and'  feel  like  suicide.  I  did  not  tell  you  this,  but  it  is  a  fact.  If  I  did  not  hope 
that  medical  science  has  some  cure  for  my  terrible  disease  I  doubtless  would  make 
away  with  myself  ere  long.  I  wish  that  at  my  next  visit  to  you  you  Avould  examine 
my  rectum.  I  am  sure  there  is  something  wrong  there,  for  just  before  and  after  my 
bowels  move  I  feel  a  peculiar  crawling  sensation  that  starts  just  at  the  opening  of  the 
bowel  and  passes  along  the  stride  into  the  testicles.  I  notice,  too,*  that  these  organs — 
the  testicles — are  sometimes  drawn  up  tightly  and  at  other  times  hang  quite  low,  the 
left  one  actually  dragging  at  times.  I  have  frequent  palpitations,  as  I  told  you,  but 
perhaps  I  did  not  tell  you  that  at  such  times  there  is  a  strange  tickling  and  fluttering 
feeling  at  my  heart  which  has  a  tendency  to  cause  a  sense  of  suffocation.  I  think  that 
I  have  given  you  the. most  important  symptoms  that  have  occurred  to  me  as  being 
necessary  to  give  you  besides  those  I  told  you  of  yesterday,  but,  if  you  do  not  mind, 
I  will  bring  a  full  written  list  of  all  of  them  the  next  time  I  come,  which  will  assist 
you  a  great  deal  in  the  treatment  of  the  case. 

Yery  truly  yours. 


Treatment. — General  Considerations. — In  considering  the  therapeutics 
of  spermatorrhea  a  knowledge  of  the  relations  of  the  involuntary  seminal 
discharges  to  various  organic  and  functional  disturbances  of  the  sexual  organs 
or  nervous  system^— or  both — is  of  paramount  importance.  A  knowledge 
of  the  pathologic  conditions  underhdng  seminal  losses  is  especially  valu- 
able in  assigning  to  spermatorrhea  its  proper  role — that  of  a  symptom. 
Understanding  the  symptomatic  character  of  involuntary  seminal  losses,  the 
physician  is  not  likely  to  overrate  the  importance  of  certain  very  common 
cases  in  which  the  involuntary  discharges  constitute  but  little,  if  an}^,  de- 
parture from  the  strictly  physiologic.     If,  however,  he  labors  under  the 


TREATMENT  OF  SPEEMATOEEHEA.  615 

erroneous  impression  that  the  disease-entity  consists  merely  in  involuntary 
discharges  of  semen,  he  is  likely  to  be  unnecessarily  alarmed,  and,  what  is 
worse,  he  is  likely  to  seriously  alarm  his  patient.  In  true  spermatorrhea 
it  is  to  be  remembered  that,  while  the  disease  is  essentially  a  neurosis — 
according  to  the  author's  view — there  are  often  associated  with  the  neu- 
rosis pathologic  conditions  of  the  genito-urinary  system  that  demand  at- . 
tention.  These  pathologic  changes  may  have  arisen  coineidently  with  the 
neurosis — being  produced  by  the  same  causes — or  they  may  either  precede 
or  follow  the  neurosis — being  due  to  causes  absolutely  independent  of  those 
producing  the  latter.  No  matter  what  relation  pathologic  changes  in  the 
genito-urinary  system  may  bear  to  spermatorrhea,  no  form  of  treatment  is 
likely  to  be  successful  that  does  not  aim  not  only  at  the  correction  of  the 
essential  neuropathic  condition,  but  also  at  the  removal  of  co-existing  local 
derangements.  Thus,  while,  in  the  author's  opinion,  deep-seated  gonorrheal 
infection  does  not  cause  spermatorrhea,  it  may  co-exist  with,  and  constitute 
a  very  important  and  obstinate  factor  in  the  perpetuation  of  that  disease. 
An  intelligent  therapy  of  .  spermatorrhea  must  necessarily  comprehend 
proper  treatment  for  the  conditions  produced  by  the  deep  infection,  what- 
ever such  conditions  may  be. 

The  majority  of  cases  of  pseudospermatorrhea  are  due  to  conditions 
that  are  essentially,  if  not  absolutely,  physiologic.  This  has  come  to  be 
generally  accepted  by  reputable  physicians.  Unfortunately,  however,  it  has 
too  often  been  taken  for  granted  that  the  patient  is  quite  as  well  balanced 
mentally,  and  should  be  quite  as  well  versed  in  the  principles  of  physiology, 
as  his  medical  adviser.  When  a  youth,  perhaps  barely  past  puberty,  im- 
mature of  mental  development,  and  unstable  of  nervous  system — to  say 
nothing  of  the  melancholy  and  hypochondriasis  produced  by  ungratified 
sexual  desire  and  brooding  over  an  imaginary  spermatorrhea — presents  him- 
self to  the  average  reputable  practitioner,  he  is  either  laughed  at  for  his 
ignorance  or  informed  that  his  case  is  not  worthy  of  serious  consideration. 
He  is  rarely  convinced,  however,  that  his  case  is  deserving  of  ridicule,  still 
less  that  his  symptoms  are  "trifles  light  as  air."  On  the  contrary,  he  be- 
comes convinced  that  his  case  is  either  more  serious  or  offensive  than  his 
physician  cares  to  undertake,  or  else  that  the  derision  aroused  by  his  tale 
of  woe  is  merely  a  subterfuge  to  conceal  medical  ignorance.  Should  he 
chance  to  consult  with  a  lay  friend,  more  experienced  than  himself,  he  is 
informed  that,  from  esthetic  motives,  ordinary  physicians  object  to  treat- 
ing, or  even  studjdng,  such  important  and  serious  cases  as  his  own.  The 
quack,  that  court  of  last  resort  for  the  ignorant  and  incurable,  is  suggested 
and  finally  appealed  to. 

The  author  has  no  hesitancy  in  asserting  that  the  reputable  profession 
is  itself  largely  responsible  for  the  opulence  and  indisputable  power  of  the 
quack.  Would  it  not  be  better  to  employ  the  same  psychic  instability  that 
is  utilized  by  the  quack  for  the  purpose  of  alarming  the  patient  and  preying 


616  SPEEMATOEEHEA. 

upon  his  fears,  in  an  honest  endeavor  to  correct  his  psychopathic  state? 
Therapeutic  suggestion,  honestly — which  means  scientifically — used  will  re- 
lieve most  cases  of  pseudospermatorrhea,  both  psychically  and  physically, 
and  keep  them  out  of  the  hands  of  the  harpies  that  find  in  such  patients 
their  most  lucrative  victims.  The  patient  should  be  given  to  understand 
primarily  that,  while  his  case  demands  attention,  it  is  by  no  means  so  serious 
as  he  supposes  and  will  yield  readily  to  treatment.  He  should  be  instructed 
in  sexual  physiology,  but  not  expected  to  become  an  adept  in  one  lesson. 
Such  organic  or  functional  disturbances  as  may  have  a  bearing  upon  his 
symptoms  demand  careful  attention.  Oftentimes  regulation  of  the  diet, 
attention  to  the  bowels,  and  the  passage  of  the  cold  sound  a  few  times  will 
lessen  the  frequency  of  emissions  which  the  practitioner  pronoimces  off- 
hand, physiologic.  If,  in  the  meantime,  the  patient's  confidence  has  been 
gained  and  proper  psychic  control  attained,  the  result  is  likely  to  be  all 
that  could  be  desired.  There  are  very  few  spermatophobiacs  who  do  not 
demand  careful  attention,  for,  no  matter  how  trivial  the  sexual  derange- 
ment per  se,  the  patient's  psychic  state  is  such  as  to  make  his  ailments 
terribly  real  to  him.  The  author  takes  this  opportunity  of  saying  that  in 
his  opinion  the  neglect  of  the  profession  to  do  its  full  dut}^  in  such  cases 
is  responsible  for  much  suffering — -both  mental  and  physical.  It  is,  of 
course,  understood  that  there  are  occasional  cases  in  which  a  perfectly- 
healthy  subject  consults  the  physician  regarding  infrequent  emissions  the 
significance  of  which  the  patient  does  not  understand  and  whom_it  is  per- 
fectly safe  to  dismiss  with  a  few  words  of  instruction  in  sexual  physiology. 
It  is  to  be  remembered,  however,  that  the  practitioner  is  not  often  consulted 
until  the  patient  has  developed  a  psychopathic  state  that  demands  the  most 
judicious  management. 

Prophylaxis.  —  Subservience  to  the  rules  of  sexual  hygiene  is  pre- 
ventive of  both  pseudospermatorrhea  and  real  spermatorrhea,  save  in  ex- 
ceptional instances  where  the  seminal  losses  are  symptomatic  of,  or  sec- 
ondary to,  debilitating  general  diseases  or  lesions  of  the  nervous  system. 
Even  in  the  case  of  locomotor  ataxia,  however,  it  is  to  be  remarked  that 
proper  sexual  habits  ma}'  be  prophylactic,  for  it  is  probable  that  sexual 
excesses  bear  a  very  important  etiologic  relation  to  that  disease.  The  vari- 
ous features  of  genito-urinary  and  sexual  hygiene  have  been  discussed  in 
the  special  chapter  devoted  to  that  subject,  and  have  received  especial  at- 
tention in  the  chapters  upon  impotence,  sterilit}'',  and  masturbation.  The 
cure  of  local  organic  disturbances  of  the  sexual  organs  is  obviously  prophy- 
lactic of  spermatorrhea. 

Special  Treatment. — In  considering  the  treatment  of  pseudosperma- 
torrhea it  is  well  to  remember  that  in  the  form  characterized  by  more  or 
less  frequent  involuntary  emissions  the  frequency  of  their  occurrence  is  not 
the  sole  criterion  of  their  importance.  The  important  point  is  the  degree 
of  tolerance  of  the  emissions.    Just  as  some  individuals  may  copulate  very 


TKEATMENT  OF  SPERMATORRHEA.  617 

frequently  without  apparent  harm,  certain  plethoric  subjects  may  appar- 
ently tolerate  involuntary  emissions  that  would  produce  most  disastrous 
results  in  feebler  subjects.  It  is  to  be  remarked,  however,  that  frequent 
emissions  are  in  themselves  usually  a  sign  of  disturbed  innervation  both 
of  the  sexual  organs  and  general  nervous  system,  or  of  some  local  source 
of  reflex  irritation.  Before  deciding  the  question  of  the  necessity  of  treat- 
ment, even  in  apparently  slight  cases,  it  is  wise  to  ascertain  the  condition 
of  the  sexual  organs.  The  emissions  may  be  a  symptom  of  local  disturbance 
of  a  congestive  or  inflammatory  character  that  may  later  on  cause  serious 
trouble,  but  which  may  be  readily  relieved  by  proper  early  attention. 

By  far  the  most  important  measure  of  general  treatment  in  the  class 
of  subjects  seeking  advice  in  pseudospermatorrhea  is  physical  training. 
With  careful  development  of  the  muscular  system  will  come  improvement 
in  nervous  tone,  both  general  and  local.  Exercise  should,  so  far  as  pos- 
sible, be  taken  in  the  open  air,  although  field-sports  should  be  aided  by 
proper  gymnastic  training  to  secure  general  and  symmetric  muscular  de- 
velopment. Exercises  involving  pressure  or  strain  upon  the  perineum 
should  be  avoided,  as  a  rule.  Climbing,  bicycling,  and  horseback-riding  are 
especially  perniciolis.  The  cold  bath  or  cold  shower — very  cautiously  used 
at  first — constitute  an  auxiliary  measure  of  great  value.  The  baths  should 
not  be  prolonged — stimulation,  not  sedation  or  refrigeration,  is  desired — 
and  should  be  followed  by  brisk  toweling,  or  rubbing,  either  with  the  hands 
of  an  attendant  or  by  means  of  a  flesh-brush  wielded  by  the  patient  him- 
self. The  functions  of  the  kidney  and  bowel,  and  especially  of  the  stom- 
ach, demand  attention  in  all  cases  of  sexual  disturbance.  Constipation  and 
excesses  or  indiscretions  in  eating  and  drinking  are  particularly  to  be 
avoided.  Sexual  rest — both  psychic  and  physical — is  a  sine  qua  non,  save 
in  certain  cases  where  matrimony  is  advisable,  either  primarily,  or  after 
a  suitable  course  of  treatment. 

It  is  not,  as  a  rule,  difficult  to  elicit  a  history  of  the  usual  cause  of 
spermatorrhea — masturbation — in  most  cases.  The  patient's  frankness, 
however,  often  has  a  limit.  He  alludes  to  the  habit  of  masturbation  in  the 
past  tense,  and  forgets  to  inform  the  physician  that  he  has  not  yet  discon- 
tinued the  practice.  If  the  inquiry  be  pressed  closely,  he  usually  lies  out- 
right. It  has  been  the  author's  experience,  however,  that  a  large  proportion 
of  such  patients  can  eventually  be  induced  to  betray  themselves.  A  popular 
method  of  deceiving  the  physician  is  to  inform  him  that  masturbation  is 
performed  unconsciously  during  sleep.  This  is  a  possible,  but  unquestion- 
ably rare,  occurrence. 

A  very  valuable  method  of  diminishing  the  frequency  of  seminal  emis- 
sions is  sleeping  upon  a  hard  and  uncomfortable  bed.  Patients  occasionally 
discover  this  for  themselves.  Several  patients  of  the  author's  have  derived 
excellent  results  from  sleeping  upon  the  floor.  A  hard  mattress  is  often 
effective.    Physical  discomfort  and  erotism  are  somewhat  incompatible,  and 


618  SPEEMATOEKHEA. 

the  patient  whose  bones  and  muscles  are  aching  from  a  vain  effort  to  find 
comfortable  and  luxurious  repose  is  not  very  likely  to  be  disturbed  by 
lascivious  dreams.  A  few  weeks  of  this  practice  will  often  break  up  the 
emission-habit.  Light  and  relatively  cool  covering  is  advantageous.  In  a 
general  way,  the  tendency  to  nocturnal  emissions  is  directly  proportionate 
to  the  liLKuriousness  and  warmth  of  the  bed. 

Certain  mechanic  appliances  have  been  used  to  break  up  the  emission- 
habit.  The  most  effective  of  these  is  the  so-called  "spermatorrhea-ring." 
Although  originally  a  quack  device,  this  appliance  is  often  successful.  It 
consists  of  a  double  ring  adapted  to  the  circumference  of  the  penis  when 
flaccid.  The  inner  or  elastic  ring  holds  the  appliance  in  situ  after  it  has 
been  slipped  upon  the  penis,  while  the  outer  ring,  which  is  provided  with 
moderately  sharp  metallic  serrations,  inflicts  punishment  upon  the  mem- 
ber Avhenever  it  chances  to  become  erect.  The  ring  is  to  be  applied  at 
night  and,  as  a  rule,  if  an  erection  occurs  the  patient  is  immediately  awak- 
ened— before  an  emission  can  take  place.  In  some  cases  erection  and  emis- 
sion occur  despite  the  appliance.  In  true  spermatorrhea  such  devices  are 
ineffective.  A  very  ingenious  device  is  a  similar  appliance  connected  with 
a  small  battery  placed  beneath  the  patient's  pillow.  An  erection  completes 
the  circuit  and  causes  a  small  alarm  bell  to  ring,  awakening  the  patient  and 
thus  forestalling  emission. 

Any  plan  that  will  serve  to  interrupt  the  emission-habit  is  likely  to 
be  successful.  It  has  been  noted  that  the  dorsal  decubitus  favors  emissions, 
theoretically  because  in  this  position  there  is  a  determination  of  blood  to 
the  genito-spinal  center — relative  hyperemia — -with  consequent  heightening 
of  reflex  sensibility. 

In  many  cases  the  patient  rarely,  if  ever,  has  an  emission  while  lying 
upon  his  side.  Under  such  circumstances  a  towel  tied  about  the  body  in 
such  a  manner  that  the  knot  rests  in  the  middle  of  the  back,  often  serves 
to  awaken  the  patient,  or  make  him  so  uncomfortable  that  he  instinctively 
and  unconsciously  avoids  the  dorsal  decubitus.^  In  some  cases  the  patient 
has  emissions  only  while  lying  upon  one  or  the  other  side.  Changing  to 
the  opposite  side  is  often  effectual  under  such  circumstances. 

In  cases  in  which  the  patient  fosters  emissions  by  handling  the  genitals 
during  sleep,  the  author  has  advised  the  patient  to  wear  a  pair  of  ordinary 
boxing-gloves  at  night.  This  simple  device  renders  manual  manipulation 
of  the  genitalia  quite  difficult. 

In  all  forms  of  spermatorrhea  complicated  by  chronic  congestion  or 
inflammation  of  the  prostate  or — as  is  frequently  the  case — by  chronic  in- 
flammation of  the  vesiculse  seminales,  the  most  important  measure  of  treat- 
ment is  massage,  performed  by  the  flnger  of  the  surgeon  via  the  rectum. 
Instruments  have  been  devised  for  the  performance  of  prostatic  and  ve- 


"The  Reproductive  Organs,"  William  Acton. 


TEEATMENT  OF  SPEEMATOEEHEA.  619 

sicular  massage,  but  digital  massage  is  the  only  safe,  intelligent,  and  reliable 
method.  Considerable  experience  is,  moreover,  necessary  to  the  proper  per- 
formance of  the  massage.  The  surgeon  with  short  stubby  fingers  merely 
wastes  his  time  in  attempting  to  perform  this  manipulation,  which  is  in 
itself  sufficiently  simple. 

Aphrodisiac  remedies,  like  those  of  an  opposite  character,  are  used  far 
too  recklessly  in  spermatorrhea.  This  is  natural  enough,  considering  (1) 
that  the  profession  in  general  overrates  the  potency  of  this  class  of  reme- 
dies, and  (2)  the  imperative  demand  of  the  patient  to  be  relieved  of  the 
sexual  incapacity  that  often  exists  in  pseudospermatorrhea  and  almost  al- 
ways in  true  spermatorrhea. 

In  the  author's  opinion  there  is  no  class  of  remedies  so  fallacious  as 
the  aphrodisiacs.  Erections  produced  to  meet  emergencies  by  large  doses 
of  aphrodisiac  drugs  are  pathologic,  and  inevitably  followed  by  a  reactionary 
depression  which  makes  the  patient's  sexual  powers  more  unreliable  than 
ever,  to  say  nothing  of  the  local  irritation  produced  by  the  action  of  such 
drugs  upon  the  genito-urinary  mucosa.  In  moderate  doses,  however,  with 
a  clear  understanding  of  their  tonic  rather  than  their  aphrodisiac  proper- 
ties, there  are  a  number  of  drugs  that  have  a  markedly  beneficial  effect  in 
all  forms  of  sexual  debility,  whether  characterized  by  spermatorrhea  or  not. 
Of  these  drugs,  phosphorus  is  the  most  reliable,  where  tolerated  by  the 
stomach.  It  is  best  given  in  the  pure  state  in  pill  form,  but  the  dilute  phos- 
phoric acid,  the  phosphid  of  zinc,  and  the  hypophosphites  are  quite  serv- 
iceable. Nux  vomica  or  strychnia  and  its  preparations  come  next  in  order, 
and  may  advantageously  be  combined  with  phosphorus.  Ergot  is  also  useful 
as  tending  to  restore  muscular  and  vascular  tone  in  the  genital  apparatus. 
It  also  tends  to  the  correction  of  nervous  hyperactivity  of  all  kiiids,  and  is 
too  seldom  employed  with  this  object  in  view. 

The  most  overrated  remedy  for  diseases  of  the  sexual  apparatus  is 
damiana.  That  this  drug  has  a  tonic  effect  in  spermatorrhea  and  sexual 
debility  in  general  is  true,  but  as  an  aphrodisiac  it  is  an  arrant  fraud.  In 
general,  it  is  inferior  to  strychnia.  The  drug  should  be  given  in  liberal 
doses — 2  to  5  grains  of  its  solid  or  1  to  2  drams  of  the  fiuid  extract  three 
or  four  times  daily. 

Cantharides  is  the  most  popular  of  all  remedies  of  the  aphrodisiac  class. 
It  has  been  the  basis  of  "love-philters"  from  time  immemorial.  Its  true 
worth,  however,  can  be  summed  up  in  very  few  words.  As  an  aphrodisiac  it 
is  not  only  unreliable,  but  such  results  as  may  be  obtained  by  large  doses  are 
pathologic,  and  therefore  dangerous.  Given  in  rational  doses  as  a  tonic, 
it  is  serviceable  to  a  moderate  degree.  It  seemingly  has  a  general  tonic 
effect,  and  in  addition  a  somewhat  stimulating  action  upon  the  nerves  of 
sexual  sensibility  and  the  genito-spinal  center.  A  marked  degree  of  sexual 
stimulation  is  never  to  be  obtained  save  by  dangerously  large  doses.  Nor 
is  the  drug  always  reliable  in  producing  in  rational  doses  even  a  mild  degree 


620  SPEEMATOEEHEA. 

of  stimulation  of  the  sexual  apparatus.  It  has  been  claimed — and  it  must 
be  confessed  with  some  reason — that  cantharides  acts  locally  only  by  yirtue 
of  its  irritant  action  upon  the  genito-urinary  mucosa  via  the  urine.  If  this 
be  true,  any  stimulating  effect  upon  the  genito-spinal  center  and  nerves 
or  sexual  sensibility  must  be  produced  reflexly.  The  possibility  of  the 
drug^s  acting  by  virtue  of  an  irritant  effect  upon  the  mucous  surfaces  of 
the  genito-urinary  tract  should  impose  additional  caution  in  its  adminis- 
tration where  inflammatory  or  congestive  conditions  of  the  sexual  organs 
exist.  A  dose  of  more  than  20  minims  of  the  tincture  should  rarely  be 
exceeded,  although  by  increasing  one  minim  daily,  as  suggested  in  the  pre- 
ceding chapter,  this  dose  may  sometimes  be  exceeded. 

When  malformations  of  the  sexual  organs  exist  tliey  should  be  cor- 
rected by  surgical  measures  so  far  as  possible.  Phimosis  and  meatal  stenosis 
demand  attention  with  especial  frequency.  The  various  other  conditions 
already  enumerated  under  the  head  of  predisposing  causes  should  be  sought 
for,  and  if  found  should  receive  appropriate  surgical  treatment.  Disturb- 
ances located  in  the  rectum  and  anus  are  quite  frequently  overlooked. 
These  conditions  are  important  sources  of  exaggeration  of  the  genital  re- 
flexes, and  require  most   careful   consideration. 

Varicocele,  if  large,  always  demands  operation.  Even  in  the  milder 
forms  the  patient's  psychopathic  state  is  such  that  an  operation  is  often  not 
only  justifiable,  but  positively  indicated. 

Such  conditions  as  prostatorrhea  from  prostatic  hyperemia  or  follicular 
prostatitis  have  received  attention  elsewhere  in  this  volume.  Seminal  dis- 
charges during  a  dithcult  stool  should  be  explained  to  the  patient,  and  his 
constipation  relieved.  In  many  such  cases  the  prostate  is  the  seat  of  hjqDer- 
emia  or  inflammation  demanding  especial  attention.  Hypersecretion  dur- 
ing erection  and  the  appearance  of  spermatozoids  in  the  urine  after  sexual 
intercourse  or  excitement  should  be  explained  to  the  patient  upon  a  physio- 
logic basis. 

Anaphrodisiac  measures  constitute  the  most  popular  routine  treatment 
for  spermatorrhea.  In  the  author's  opinion,  however,  remedies  of  this  class 
are  much  abused.  In  cases  of  what  may  be  termed  the  sthenic  type,  charac- 
terized by  a  greater  or  less  degree  of  constitutional  vigor  associated  with 
marked  sexual  irritabilit}^,  anaphrodisiac  measures  are  a  distinct  advantage. 
The  bromids  in  free  doses,  gelsemium,  camphor,  and  lupulin  are  types  of 
this  class  of  remedies.  In  many  cases  remedies  directed  to  the  alleviation 
of  irritation  of  the  mucous  membrane  are  distinctly  anaphrodisiac.  Alka- 
lies— the  salts  of  lithia  especially,  if  the  subject  be  lithemic — and  such 
remedies  as  pichi,  buchu,  ustilago  maydis,  triticum  repens,  and  the  balsams 
are  of  service  under  such  circumstances. 

In  a  large  proportion  of  cases  of  pseudospermatorrhea,  and  in  a  ma- 
jority of,  if  not  all,  cases  of  true  spermatorrhea,  a  tonic  rather  than,  a  seda- 
tive line  of  therapy  is  demanded.     The  use  of  remedies  of  the  aphrodisiac 


TREATMENT    OF    SPEEilATOERHEA.  621 

class  as  tonics  has  already  been  dwelt  upon.  Proper  exercise  and  bathing 
for  improving  nervous  tone  have  also  received  attention.  Quinin,  arsenic, 
manganese,  and  iron — the  latter  two  especially  if  anemia  exists — are  often  of 
distinct  service.  The  fluid  extract  of  salix  nigra  has  seemed  serviceable  as  a 
sexual  tonic.  It  is  well  to  remember  that  in  the  class  of  affections  under 
consideration  tonics  should  generally  be  combined  with  suitable  mild  laxa- 
tives. Constipation  is  nowhere  more  pernicious  in  its  effects  than  in  diseases 
involving  the  sexual  functions.  One  of  the  best  ferruginous  preparations  is 
ferratin  in  tablet  form.  Peptomangan  is  an  excellent  combination  of  man- 
ganese and  iron.  One  of  the  most  valuable  tonics  at  our  command  is  static 
electricity.  The  general  tonic  effect  of  the  static  current  is  not  so  generally 
appreciated  by  the  profession  as  it  deserves.  That  the  moral  effect  of  the 
spark  is  valuable  in  pseudospermatorrhea  is  obvious. 

A  simple  yet  often  effective  tonic  treatment  is  the  free  ingestion  of  raw 
eggs.  The  popular  notion  of  the  efficacy  of  eggs  as  an  aphrodisiac  is,  of 
course,  a  fallacy,  yet  their  effects  as  a  tonic  must  be  admitted  and,  more- 
over, they  seem  to  have  a  special  tonic  effect  upon  the  sexual  apparatus. 
In  several  cases  of  very  frequent  nocturnal  emissions  in  sickly,  delicate  lads 
the  author  has  obtained  excellent  results  from  the  free  use  of  raw  eggs. 
Whether  the  beneficial  effect  of  egg  is  to  a  certain  extent  due  to  the  small 
amount  of  contained  phosphorus  is  open  to  question;  its  efficacy  may  well 
be  attributed  simply  to  its  highly  nutritive  properties. 

Psychotherapy  has  a  wide  and  important  field  of  usefulness  in  the 
various  forms  of  spermatorrhea.  Suggestion  necessarily  enters  into  all 
methods  of  treatment  to  a  certain  degree.  Cases  occur,  however,  in  which 
positive  efforts  in  this  special  direction  are  warrantable.  The  services  of 
the  specialist  in  psychotherapy — or  suggestion-therapy — may  sometimes  be 
enlisted  to  good  advantage. 

The  treatment  of  spermatorrhea  secondary  to  organic  cerebro-spinal 
disease  necessarily  resolves  itself  into  the  treatment  of  the  primary  nervous 
disorder.  In  many  cases,  however,  appropriate  local  treatment  is  of  dis- 
tinct service  in  diminishing  what  is  obviously  not  only  a  serious  drain  upon 
the  patient's  vitality,  but  also  a  source  of  most  profound  psychic  de- 
pression. 

Cold  sitz-baths  and  the  prolonged  local  application  of  cold  water  to 
the  genitalia — especially  the  testes — are  of  great  value  as  a  sexual  sedative 
primarily,  and  more  remotely  in  improving  the  tone  of  the  sexual  organs. 
Galvanism  applied  to  the  external  surface  of  the  genitals  or,  in  selected 
cases,  directly  to  the  prostate  via  the  rectal  or  deep  urethral  electrode,  is 
often  very  serviceable.  The  faradic  current,  however,  often  acts  better  when 
the  condition  is  largely  psychopathic,  because  of  the  moral  effect  of  the 
sound  of  the  rheotome.  Cold-water  enemata  are  often  of  service,  especially 
where  congestive  or  inflammatory  conditions  of  the  seminal  vesicles  exist. 
The  psychrophor  of  Winternitz — which  consists  essentiallv  of  a  double-cur- 


622  SPEEMATOEEHEA. 

rent  metallic  catheter — is  a  valuable  adjunct  to  the  treatment  of  cases  char- 
acterized by  urethro-prostatic  hyperesthesia.  The  psychrophor  is  intro- 
duced into  the  bladder  and  a  current  of  cold  water — -ice-water  if  necessary 
— made  to  pass  through  it  for  some  minutes — the  time  varying  with  the 
degree  of  tolerance.     This  is  to  be  repeated  daily  or  every  second  day. 

In  general^  the  urethral  sound  is  the  most  useful  instrument  for  the 
local  treatment  of  all  forms  of  spermatorrhea.  If  introduced  cold  and 
allowed  to  remain  in  the  urethra  for  from  five  to  ten  minutes  it  combines 
the  effects  of  mild  refrigeration  with  the  blunting  of  nervous  sensibility  by 
its  mechanic  action.  There  is  also  an  improvement  in  the  circulation  of 
the  prostate  produced  by  the  pressure  of  the  instrument  and  the  reactionary 
hyperemia  incidental  to  its  withdrawal.  The  milder  forms  of  pseudosper- 
matorrhea  usually  yield  readily  to  the  occasional  use  of  the  sound.  In  some 
cases  the  sound  is  painful,  though  the  psychrophor  is  well  tolerated.  Sound- 
ing should  usually  be  performed  twice  or  thrice  weekly. 

Direct  medication  of  the  prostatic  urethra — and  incidentally  of  the 
mouths  of  the  ejaculator}^  ducts — is  a  very  popular  method  of  treatment  of 
spermatorrhea.  When  judiciously  and  aseptically  applied,  various  astrin- 
gents act  well  in  these  cases.  The  most  useful  astringents  are  silver  nitrate, 
copper  sulphate,  t-annin,  thallin,  protargol,  and  ichthyol.  These  may  be  used 
in  the  form  of  suppository,  ointment,  or  solution.  The  most  useful  astringent 
is  silver-nitrate  solution  in  a  strength  of  2  ^/^  to  30  grains  to  the  ounce.  In 
the  authors  experience  a  relatively  mild  solution  in  considerable  quantity 
is  usually  best.  Where  strong  solutions  are  used,  only  a  few  drops  should 
be  injected.  The  author's  deep  urethral  syringe  (Fig.  4?)  will  be  found 
serviceable,  especially  in  using  the  milder  solutions.  With  this  syringe  the 
prostatic  urethra  can  be  thoroughly  flooded  with  the  solution.  In  using  the 
stronger  solutions  the  Keyes-Ultzmann  syringe  is  better  for  the  general 
practitioner.  If  the  instillations  are  followed  by  prostatic  massage,  their 
beneficial  effects  are  enhanced. 

The  recent  introduction  of  animal  extracts  into  medicine  has  been 
seized  upon  with  avidity  as  a  possible  solution  of  all  problems  in  the  therapy 
of  diseases  involving  the  sexual  function.  The  vaporings  of  Brown-Sequard 
were  used  as  a  justification  of  all  sorts  of  quackery,  "regular"  and  other- 
wise. The  "fake"  solutions  of  spermin  and  its  congeners,  fathered  by  a 
noted  highly-ethic  (?)  neurologic  specialist  of  this  country,  will  be  remem- 
bered in  this  connection.  In  view  of  the  nitroglycerin  upon  which  such 
action  as  these  preparations  possessed  depended,  it  is  not  surprising  that 
their  false  pretensions  have  been  exploded.  Legitimate  solutions  of  spermin 
have  been  indorsed  as  of  limited  value  by  competent  authority,^  but,  from  a 
sexual  stand-point,  nothing  so  far  discovered  has  greatly  impeded  the  on- 


'  Vecki,  Poehl.  and  Hirscli.     Tide  V.  G.  Veeki  on  "Sexual  Impotence,"  1899. 


TKEATMENT  OF  SPEEMATOERHEA.  623 

TvarcT  progression  of  remorseless  old  Father  Time,  nor  cancelled  the  debt  the 
roue  must  sooner  or  later  pay  to  Nature. 

One  of  the  most  popular  methods  of  treatment  of  spermatorrhea  among 
surgeons  of  a  past  generation  was  cauterization  of  the  prostatic  urethra  with 
pure  silver  nitrate,  via  the  porte-caustique  of  Lallemand:  an  instrument 
which,  as  the  late  M.  Eicord  Justly  said,  "  has  been  responsible  for  more 
eunuchs  than  all  the  harems  of  the  East."  Cauterization  of  the  prostate  is 
occasionally  justifiable,  but  only  in  the  hands  of  the  expert,  and  rarely  by 
any  other  method  than  via  the  endoscope  under  direct  illumination  and 
ocular  control.  The  caustic  application  should  generally  be  limited  to  the 
caput  gallinaginis,  being  made  with  the  view  of  lessening  hyperesthesia  and 
curing  chronic  inflammation  of  that  structure.  As  formerly  used,  complete 
obliteration  of  the  mouths  of  the  ejaculatory  and  prostatic  ducts  was  a  fre- 
quent result  of  the  method.  Sterility  is  a  necessary  consequence  of  such 
rough  treatment. 

Marriage  is  often  advised  in  spermatorrhea  and  its  congeners.  This 
"prescription"  involves  very  serious  responsibility.  In  some  cases  of  pseudo- 
spermatorrhea  the  physician  may  safely  advise  matrimony,  but  he  should 
use  great  care  in  determining  the  patient's  potency.  Even  psychic  impo- 
tence may  be  a  bar  to  marriage.  In  true  spermatorrhea  marriage  is  rarely 
justifiable.  The  author  has  commented  elsewhere  on  the  heinous  practice 
of  prescribing  healthy  and  presumably  innocent  women  in  the  treatment  of 
masculine  degenerates  who  cannot  be  other  than  wrecks  of  humanity. 
Oftentimes  the  game  is  not  worth  the  candle,  even  though  an  apparent 
success  be  obtained.  There  is  rarely  an  instance  in  which  the  woman  pre- 
scribed does  not  get  the  worst  of  it.  Such  offerings  upon  the  altar  of  hymen 
— to  say  nothing  of  the  still-broader  question  of  infection — are  responsible 
for  quite  a  proportion  of  the  sum-total  of  human  misery,  both  psychic  and 
physical.  Both  the  profession  and  the  public  may  one  day  awaken  to  a  sense 
of  their  duties  in  this  matter,  and  the  time  may  come  when  proposals  of 
marriage,  or,  at  least,  applications  for  a  license  to  marry,  will  be  unorthodox 
unless  accompanied  by  a  clean  bill  of  health  from  a  reputable  physician. 


PART  VIL 

DISEASES  OF  THE  PEOSTATE  AXD  SEMIKAL  VESICLES. 


CHAPTEE  XXYII. 

DISEASES  OF  THE  PROSTATE. 

AxATOMY,  Physiology,  Anomalies,  and  Ixjueies  of  the  Pkostate. 

Anatomy  and  Physiology. — An  exhaustive  anatomic  description  of 
the  prostate  would  not  comport  with  the  purpose  of  this  work;  but  it  is 
almost  impossible  to  give  a  practical  outline  of  the  various  diseases  affect- 
ing this  organ  -nithout  a  preliminary  discussion  of  some  of  the  main  points 
in  its  anatomy  and  physiology.  Especially  is  this  necessary  in  view  of  the 
fact  that  our  text-books  upon  anatomy  are  notably  defective  in  their  de- 
scriptions of  the  part.  Slight  attention  is  usually  given  to  the  prostate  in 
the  dissecting-room,  comparatively  few  students  acquiring  even  a  super- 
ficial knowledge  of  its  structure  and  functions. 

Without  entering  into  an  elaborate  discussion  of  the  views  of  those  who 
beKeve  the  prostate  to  be  essentially  a  muscle,  or  their  opponents  who  claim 
that  it  is  essentially  a  gland,  it  will  suffice  to  say  that  the  prostate  is  a  mus- 
culo-glandular  organ  surrounding  the  neck  of  the  bladder.  It  lies  behind 
the  triangular  ligament,  or  deep  perineal  fascia,  and  impinges  upon  the  rec- 
tum, through  the  thin  walls  of  which  it  may  readily  be  palpated  by  the  finger. 
The  relation  of  the  organ  to  the  rectum  is  one  of  the  most  important  of  its 
gross  anatomic  relations,  having  an  important  bearing  on  both  the  symp- 
tomatology and  diagnosis  of  prostatic  disease.  The  close  anatomic  associa- 
tion of  the  prostate  and  rectum  very  often  results  in  coincidental  disturbance 
in  both  organs  through  the  medium  of  the  associated  nerve-supply  as  a  con- 
sequence of  disease  in  one  or  the  other. 

In  a  general  way.  the  old  description  of  the  prostate  as  resembling  a 
horse-chestnut  is  fairly  accurate  as  regards  its  form  and  size.  The  organ 
measures,  on  the  average,  about  an  inch  and  a  half  in  breadth,  an  inch 
antero-posteriorly,  and  somewhat  less  than  an  inch  in  thickness.  It  is 
supported  by  the  pubo-prostatic  ligaments  derived  from  the  anterior  vesi- 
cal ligaments,  posterior  layer  of  the  triangular  ligament,  and  the  levator- 
ani  muscle.  The  organ  presents  the  appearance  of  two  moderately-distinct 
lateral  halves  or  lobes.  The  so-called  median  lobe  is  a  misnomer,  this 
structure  being  a  pathologic  formation.  It  is  not  surprising  that  such 
a  mistake  should  be'  quite  general  when  authorities  state,  as  does  one  ex- 
cellent anatomist,  that  "the  median  lobe  is  a  cause  of  obstruction  in  fully 

(624) 


ANATOMY   AND    PHYSIOLOGY    OF    THE    PEOSTATE. 


625 


20  per  cent,  of  jDrostates  after  the  age  of  sixty."  The  prostate  is  tun- 
neled by  the  urethra  and  the  prostatic  and  ejaculatory  ducts.  On  its  floor 
is  a  longitudinal,  highly-sensitive,  erectile  structure,  the  veru  montanum. 
This  is  probably  the  principal  seat  of  sexual  sensibility.  Upon  either  side 
of  the  veru  montanum  is  a  longitudinal  depression,  the  prostatic  sinus,  into 
Avhicli  open  the  prostatic  ducts,  some  fifteen  or  twenty  in  number.  At  the 
anterior  extremity  of  the  veru  montanum  are  situated  the  mouths  of  the 
ejaculatory  ducts  upon  either  side.  Just  in  front  of  the  veru  montanum- 
is  a  depression  known  as  the  uterus  mascuUnus,  or  prostatic  utricle,  from 


\YJXI 


Fig.  127. — Conventional  illustration  of  the  anatomic  relations  of  the  parts 
about  the  base  of  the  bladder.  U,  U,  Ureters.  YD,  TD,  Vasa  deferentia. 
S,  Y,  Seminal  vesicles.  P,  Prostate.  C,  G,  Cowper's  glands.  B,  Bulb  of 
the  urethra. 


its  supposed  homology  to  the  uterus.  The  prostatic  urethra  does  not  trav- 
erse the  prostate  in  the  same  manner  in  all  individuals,  the  roof  of  the 
canal  being  barely  covered  in  by  prostatic  tissue  in  some  cases.  It  does  not 
always  begin  anteriorly  in  the  center  of  the  prostatic  apex,  being  occasion- 
ally deflected  to  one  or  the  other  side.  The  length  of  the  prostatic  urethra 
and  the  direction  of  its  curve  vary  greatly.  In  the  average  adult  it  meas- 
ures about  an  inch  and  a  quarter  in  length.     Its  curve  is  quite  sharp  and 


626 


DISEASES    OE    THE    PEOSTATE. 


short  in  the  child,  longer  and  more  gradual  in  the  adult.  A  knowledge 
of  the  normal  curve  of  the  prostatic  nrethra  is  of  great  importance  in  diag- 
nostic explorations  of  the  canal,  inasmuch  as  pathologic  conditions  of  the 
organ  or  the  tissues  about  the  vesical  neck  produce  alteration  in  its  con- 
formation and  length.  The  structure  of  the  prostate  differs  somewhat  in 
children  and  adults.    The  assertion  has  been  made,  and  accepted  in  certain 


Fig.  128. — Showing  the  internal  anatomic  relations  of  the  bladder,  urethra, 
and  prostate.  A,  A,  Ureteral  orifices.  B,  Trigonum  vesicse.  C,  Veru 
montanum.  D,  Orifices  of  the  ejaculatory  ducts.  E,  E,  Cowper's  glands. 
F,  Membranous  urethra.     G,  Bulbous  urethra. 


quarters,  that  children  have  no  prostate.  This,  however,  is  incorrect.  The 
difference  between  the  child  and  the  adult  is  mainly  in  the  relative  propor- 
tion of  glandular  and  fibro-muscular  elements.  Even  in  very  young  chil- 
dren the  muscular  elements  are  sufficiently  abundant  to  give  a  sharply- 


ANATOMY   AND    PHYSIOLOGY    OF    THE    PKOSTATE.  627 

defined  and  prominent  character  to  the  organ.  The  glandular  and  fibro- 
connective-tissue  elements,  however,  are  not  so  abundant  and  well  marked 
as  in  the  adult.  The  veru  montanum,  ejaculatory  ducts,  mouths  of  the 
prostatic  follicles,  and  seminal  vesicles — which  are  so  closely  associated  with 
the  prostate  and  its  functions — are  capable  of  definite  demonstration  even 
in  young  infants.  The  argument  has  been  advanced  that  children  really 
have  no  prostate,  because,  its  function  being  purely  sexual,  there  is  no  oc- 
casion for  its  development  until  sexual  power  manifests  itself.  This  argu- 
ment is  not  particularly  logical,  in  view  of  the  fact  that  the  seminal  vesi- 
cles and  veru  montanum,  which  are  perhaps  of  more  importance  from  a 
sexual  stand-point  than  the  glandulo-muscular  elements  of  the  prostate,  are 
disproportionately  well  developed  in  infants.  Even  a  superficial  dissection 
shows  that  very  young  children  have  well-developed  prostates,  sparsity  of 
the  prostatic  glandular  tissue  to  the  contrary  notwithstanding.  In  a  general 
wa}',  however,  it  may  be  asserted  that  the  prostate  is  of  no  great  functional 
importance  until  puberty  arrives. 

Whether  or  not  the  muscular  tissue  of  the  prostate  is  of  importance  in 
micturition,  thus  rendering  the  organ  to  a  certain  extent  a  urinary  one,  is 
a  question  that  has  awakened  much  controversy.  In  the  authors  estima- 
tion, Avhile  urination  might  be  carried  on  in  the  absence  of  the  muscular 
tissue  of  the  prostate,  the  organ  nevertheless  appears  to  play  a  distinct  sec- 
ondary or  auxiliary  role  in  micturition.  While  admitting,  therefore,  that 
the  prostate  is  to  all  intents  and  purposes  a  procreative  organ,  it  would  seem 
that  it  is  a  participant  in  the  function  of  micturition,  and  should  therefore 
receive  consideration  as  a  urinary  organ  as  well. 

In  infants  the  author  has  demonstrated  that  the  muscular  structure  of 
the  prostate  is  practically  continuous  with  the  muscular  structures  of  the 
vesical  walls.  As  the  subject  grows  older  a  certain  amount  of  circumscrip- 
tion and  reinforcement  of  the  prostatic  muscular  tissue  seems  to  occur,  so 
that  there  is  a  more  distinct  line  of  demarkation  between  the  prostatic  and 
vesical  muscular  tissue,  although  the  circular  fibers  of  the  prostate  are  still 
continuous  at  the  outlet  of  the  bladder  with  the  false  vesical  sphincter. 

On  section  the  prostate  is  of  a  pale-reddish  color,  rather  dense  and 
firm,  and  quite  friable,  the  fibro-muscular  elements  being  contained  in  a 
proper  fibrous  capsule.  The  impression  derived  from  the  usual  descriptions 
of  the  prostate  is  that  its  glandular,  and  consequently  its  most  important, 
elements  from  a  functional  stand-point  are  contained  within  the  proper 
fibrous  capsule.  This  is  an  error.  The  principal  glandular  elements  of  the 
organ  are  outside  the  circumscribed  structure  that  we  know  as  the  pros- 
tate body  proper,  in  the  tissues  surrounding  the  prostate,  seminal  vesicles, 
and  vesical  neck.  The  glands  and  ducts  are  numerous,  forming  the  tissue- 
mass  of  which  the  seminal  vesicles  constitute  the  most  important  part.  This 
tissue  is  richly  supplied  with  nerves  and  blood-vessels.  A  consideration  of 
this  particular  feature  of  the  anatomy  of  the  prostate  serves  to  explain  the 


628  DISEASES    OF    THE    PKCSTATE. 

obstinacy  of  infectious  diseases  involving  the  organ,  and  lays  peculiar  em- 
phasis upon  the  oft-repeated  assertion  of  the  intrinsic  incurability  of  gon- 
orrheal infections  of  this  part.  A  careful  dissection  of  the  prostate  and 
its  associated  glandular  structures  about  the  vesical  neck  should  be  very  in- 
teresting to  those  who  believe  that  deep  gonorrheal  infection  in  the  male 
may  be  speedily  cured  by  instilling  a  few  drops  of  silver-nitrate  solution 
into  the  prostatic  urethra. 

The  muscular  elements  are  arranged  in  a  circular  fashion,  forming  pos- 
teriorly a  rather  distinct  muscular  ring,  constituting  the  dividing-line  be- 
tween the  vesical  cavity  and  the  true  vesical  neck:  i.e.,  the  prostatic  urethra. 
This  ring  of  circular  fibers  constitutes  the  internal  or  false  sphincter  vesicae. 
Anteriorly  the  muscular  fibers  of  the  prostate  are  continuous  with  the  ac- 
celerator-uringe  muscle  surrounding  the  membranous  urethra.  It  is  difficult 
to  say  whether  the  false  sphincter  vesicae  is  a  part  of  the  muscular  structure 
of  the  vesical  wall  or  of  the  prostate.  This  point  is  of  no  great  moment  inas- 
much as  there  is  practically  a  structural  and  functional  continuity  between 
the  prostate  and  bladder-muscle  even  in  the  adult.  The  tendency  has  been 
in  the  direction  of  a  too-arbitrary  differentiation  of  the  two  organs:  a  dif- 
ferentiation hardly  warrantable  from  a  physiologic  stand-point,  save  in  so 
far  as  the  sexual  function  of  the  prostate  is  concerned. 

The  circulatory  supply  of  the  prostate  is  very  rich.  The  arteries  are 
derived  from  the  internal  pudic,  hemorrhoidal,  and  vesical.  The  veins  form 
an  elaborate  and  intricate  plexus  about  the  organ,  inosculating  with  those 
supplying  the  rectum  and  anus  in  a  very  intimate  manner.  This  peculiar 
relationship  of  the  vascular  supply  of  the  rectum,  anus,  and  prostate  ex- 
plains, to  a  certain  degree,  their  close  pathologic  relationship.  Thus,  hemor- 
rhoids, constipation,  and  hepatic  obstruction  are  liable  to  lead  to  passive 
congestion  of  the  prostate,  and  even  predispose  to  active  inflammation. 
Conversel}^,  inflammatory  and  congestive  prostatic  disturbances  may  pro- 
duce rectal  tenesmus,  hemorrhoids,  or  even  proctitis.  The  veins  of  the  pro- 
static plexus  are  prone  to  become  tortuous  and  varicose  in  elderly  subjects: 
a  condition  that  is  often  associated  with  hemorrhoidal  disease. 

The  nerve-supply  of  the  prostate  is  derived  mainly  from  the  hypogas- 
tric plexus.  The  organ  is  liberally  supplied  with  filaments  from  the  sym- 
pathetic. This  sympathetic  supply  is  closely  associated  with  that  of  the 
rectum  and  anus:  a  relationship  that  in  some  cases  forms  another  strong 
pathologic  link  between  the  two  organs.  The  consideration  of  the  nerve- 
anatomy  of  these  parts  enables  us  to  understand  the  strangury,  spasmodic 
stricture,  and  retention  of  urine  that  often  occur  as  a  result  of  operations 
about  the  rectum  and  anus.  The  elaborate  sympathetic  and  sensory  nerve- 
supply  of  the  prostate,  particularly  of  the  prostatic  urethra,  is  explanatory 
of  the  more  or  less  remote  reflex  disturbances,  both  mental  and  physical,  that 
so  frequently  occur  as  a  result  of  prostatic  disease.  By  means  of  the  sympa- 
thetic nerve-supply  the  prostate  is  brought  into  most  intimate  relation  with 


■  AiSTATOMY   AND    PHYSIOLOGY    OF    THE    PKOSTATE.  629 

all  the  organs  in  the  function  of  wliich  the  s}anpathetic  ganglia  play  an  im- 
portant role. 

The  sexual  function  of  the  prostate  is  rather  complex^  comprising  sev- 
eral elements,  viz.:  special  sensory,  secretory,  and  mechanic.  While  its 
urinary  role  should  not  be  ignored,  it  is  of  no  great  moment;  the  urine 
may  be  physiologically  retained  or  expelled  independently  of  the  pros- 
tate. The  prostatic  urethra,  and  especially  its  floor  in  and  about  the  veru 
montanum,  is  the  seat  of  the  pleasurable  sensation  experienced  in  the  per- 
formance of  the  sexual  function.  The  prostatic  follicles  secrete  a  milky, 
slightly-acid  fluid,  the  function  of  which  is  to  dilute  and  increase  the  bulk 
of  the  semen.  The  muscular  fibers  of  the  prostate  are  involved  in  the  con- 
vulsive, spasmodic  perineal  contraction  that  expels  the  semen  during  ejacu- 
lation. This  is  due  to  a  distinct  reflex  contraction  excited  by  overdistension 
of  the  prostatic  urethra  with  seminal  fluid  at  a  time  when  the  nerves  of 
sexual  sensibilit}^  are  relatively  hyperesthetic. 

Standard  anatomic  authorities  assert  that  the  follicular  prostatic  glands 
in  some  old  subjects  contain  small  calculi,  composed  of  calcium  carbonate 
and  animal  matter.     This  assertion  is  based  upon  the  fact  that  it  is  prac- 


D 


Fig.    129. — Midsection   of  prostatic   urethra.     D,-  Ejaculatory   ducts. 
Sp,  Sinus  pocularis,  or  utricle.     (After  Cruveilhier.) 

tically  only  in  old  subjects  that  these  calculi  are  of  sufficient  size  or  so  lo- 
cated as  to  produce  mechanic  disturbance.  The  author  has  become  con- 
vinced from  the  dissection  of  a  large  number  of  prostates  in  subjects  under 
middle  age  that  prostatic  calculi — corpora  amylacea— are  frequently  found 
in  young  subjects.  They  are  even  found  in  children.  If  the  examination 
of  the  prostate  be  restricted  to  the  tissue  immediately  surrounding  the  pro- 
static urethra,  these  peculiar  bodies  will  not  often  be  found.  If,  however, 
the  tissue  outside  of  the  capsule  proper — i.e.,  the  glandular  tissue  surround- 
ing the  base  of  the  prostate  and  vesical  neck — ^be  carefully  examined  they 
Avill  frequently  be  met  with.  The  author  has  found  them  in  the  tissues  sur- 
rounding the  vesical  neck  fully  an  inch  above  the  base  of  the  prostate 
proper. 

Attention  has  frequently  been  called  to  certain  striking  points  of  sim- 
ilarity between  the  prostate  and  uterus,  both  anatomic  and  physiologic. 
It  is  unnecessary  to  enter  upon  an  exhaustive  discussion  of  this  subject. 
It  is  well  to  remember,  however,  the  general  resemblance  between  them  in 
the  clinical  study  of  prostatic  disease,  especially  with  reference  to  surgical 
treatment  of  circumscribed  neoplasms  and  the  medical  treatment  of  con- 


630  DISEASES    OF    THE    PEOSTATE. 

gestive  and  inflammatory  affections  of  the  organ.  The  prostate  is  neces- 
sarily a  more  obscure  field  for  research  than  the  nterns;  hence  analogic 
reasoning  is  sometimes  of  great  clinical  and  therapeutic  value. 

Anomalies  of  Development. — Congenital  anomalies  of  the  prostate 
are  clinically  rare.  They  are  probably  more  frequent  than  is  generally  sup- 
posed; but,  as  they  are  not  likely  per  se  to  prove  of  pathologic  importance, 
they  are  not  often  brought  to  our  attention.  Defective  development  in- 
cidental to  extreme  hypospadias  and  epispadias  are  occasionally  seen.  In 
these  cases  the  prostate  is  usually  absent.  This  anomaly  requires  no  con- 
sideration excepting  as  incidental  to  the  deformity  of  which  it  is  a  part. 
Defective  development  of  the  prostate  is  associated,  as  a  rule,  with  de- 
fective development  of  the  sexual  apparatus  as  a  whole.  The  prostate 
is  likely  to  be  wanting  in  cryptorchids.  In  certain  cases  of  sexual  per- 
verts, and  in  individuals  who  are  sexually  imperfectly  developed  and 
differentiated,  the  prostate  remains  undeveloped  in  both  muscular  and 
glandular  structure,  as  might  be  expected  from  the  rudimentary  condi- 
tion of  the  rest  of  the  sexual  apparatus.  The  inhibition  of  prostatic 
g-rowth  is  due,  not  to  failure  of  the  individual  to  normally  perform  his 
sexual  functions,  but  to  inhibition  of  development  that  may  be  more 
or  less  general,  and  which  always  involves  all  the  component  parts  of 
the  sexual  apparatus.  That  imperfect  or  exaggerated  development  of  the 
prostate  occurs  alone  is  possible,  but  this  is  a  question  which,  for  obvious 
reasons,  is  extremely  difficult  of  solution.  Aberrations  of  development  of 
the  most  important  structure  of  the  prostate — viz.:  the  veru  montanum — 
have  been  described.  Independently  of  infectious  or  inflammatory  disease, 
cases  of  imperfect  or  exaggerated  development  of  this  structure  probably 
occur.  It  would  be  difficult,  however,  to  eliminate  in  such  cases  the  effects 
of  masturbation  and  sexual  excess.  Stricture  of  the  prostatic  urethra  is 
asserted  by  so  excellent  an  authority  as  Thompson  to  be  unknown.  The 
author  had,  however,  at  one  time  several  specimens  in  his  possession  in 
which  distinct  bridles,  apparently  congenital,  were  present  in  the  anterior 
portion  of  the  prostatic  urethra.  Several  other  specimens  showed  an  ab- 
normal narrowing  of  the  prostatic  urethra,  with  a  distinct  lateral  deviation 
of  the  canal  at  its  junction  with  the  pars  membranosa.  In  certain  specimens 
the  prostatic  urethra,  instead  of  tunneling  the  center  of  the  apex  of  the 
prostate,  diverged  so  far  from  the  median  line  that  obstruction  to  instru- 
ments must  almost  necessarily  have  been  experienced  during  the  life  of 
the  patient,  had  instrumentation  become  necessary.  It  will  be  readily  un- 
derstood that  such  abnormal  narrowing  and  deviation  in  all  probability  pro- 
duce no  disturbance  so  long  as  there  is  no  disease  of  the  mucous  membrane. 
Should  gonorrheal  infection  occur,  however,  a  far  different  state  of  affairs 
might  supervene,  and  the  congenital  condition  produce  considerable  trouble. 
The  author  believes  that  such  congenital  aberrations  of  the  prostatic  ure- 
thra may  occasionally  be  responsible  for  difficult  urethral  instrumentation. 


WOUNDS    OF   THE    PKOSTATE.  631 


INJUEIES    OF    THE    PKOSTATE. 


Traumatism  of  the  prostate,  save 'from  surgical  operations  and  manip- 
ulations, is  exceptional.  Contusions  and  lacerations  due  to  direct  force 
from  falls  or  blows  are  especially  rare  on  account  of  the  situation  of 
the  organ,  protected  as  it  is  by  the  pubic  and  ischial  rami  and  ischial 
tuberosities.  The  force  of  falls  and  blows  upon  the  buttocks  is  usually 
broken  by  the  latter  osseous  parts.  Blows  upon  the  perineum  are  not 
likely  to  injure  the  prostate  because  of  the  distance  of  the  organ  and  the 
elasticity  of  the  musculo-cellular  cushion  constituted  by  the  tissues  of 
the  ano-perineal  region  and  ischio-reetal  fossa.  Accidents  have  been 
known  where  the  membranous  urethra  has  been  torn  completely  across  at 
the  apex  of  the  prostate,  yet  that  organ  has  escaped  injury.  Crushing 
injuries  involving  the  prostate  are  almost  necessarily  fatal,  excepting 
where  the  prostate  is  injured  indirectly  through  the  medium  of  fractured 
pelvic  bones  that  are  driven  into  the  organ.  In  extensive  crushing  injuries 
the  traumatism  of  the  prostate  is  comparatively  a  minor  consideration.  In- 
cised, punctured,  and  lacerated  wounds  of  the  prostate  from  accidental  in- 
jury are  occasionally  seen.  Sharp  bodies  may  be  driven  into  the  perineum, 
the  patient  perhaps  falling  astride  them.  Most  of  the  accidental  injuries  are 
due  to  a  fall  upon  some  pointed  object.  Dugas  cites  a  case  in  which  the 
branch  of  a  tree  was  driven  into  the  perineum  and  the  prostate  wounded. 
A^elpeau  reported  a  similar  case  in  which  a  wooden  stake  was  driven  into  the 
perineum.  Brittle  substances  introduced  into  the  rectum  have  been  known 
to  penetrate  the  prostate.  Obviously  such  penetration  can  occur  with 
great  facility.  Injury  to  the  prostate  by  fire-arms  is  necessarily  very  rare. 
Eicord,  however,  reported  a  case  in  which  a  musket-ball  penetrated  the  false 
pelvis,  passed  downward  along  the  iliac  fossa,  entered  the  true  pelvis,  and 
penetrated  the  prostate.  It  v/as  detected  by  digital  examination  of  the  rec- 
tum and  extracted  by  perineal  section.  Wounds  of  the  prostate  inflicted  in 
surgical  operations  are  frequent.  It  is  necessarily  wounded  in  all  perineal 
lithotomies  with  the  exception  of  the  simple  median  operation.  It  is  often 
wounded  in  perineal  urethrotomy,  and  invariably  wounded  in  the  proper 
performance  of  perineal  puncture  for  vesical  drainage.  Operative  wounds 
are  not  dangerous  per  se,  unless  the  incision  or  laceration,  as  in  the  case  of 
extraction  of  too  large  a  stone,  extends  beyond  the  bounds  of  the  fascial 
investments  of  the  prostate,  thus  involving  the  pelvic  cellular  tissue  or  peri- 
toneum. The  prostate  is  often  injured  from  its  urethral  aspect  in  the  pas- 
sage of  the  catheter  or  sound,  or  in  the  performance  of  that  extremely  haz- 
ardous operation,  internal  prostatotomy.  These  forms  of  prostatic  trauma 
are  exceedingly  dangerous  because  of  the  exposure  of  the  injured  tissue  to 
sepsis  and  the  necessarily-imperfect  drainage.  An  additional  element  of 
danger  is  uncontrollable  hemorrhage.  These  factors  are  done  away  with  in 
perineal  or  suprapubic  operative  wounds  of  the  prostate.    Another  danger 


632  DISEASES    OF    THE    PROSTATE. 

is  the  formation  of  a  false  urinary  passage.  False  passages  traversing  the 
prostate  and  beginning  in  the  prostatic  nrethra  or  at  some  point  in  the 
nrethral  walls  at  a  greater  or  less  distance  anterior  to  the  apex  of  the  organ 
are  frequently  seen.  Instances  have  been  known  in  which  a  catheter  or 
soimd  has  been  passed  through  the  urethral  walls  at  some  point  in  front 
of  the  bulbo-m'embranons  region,  traversing  the  tissues  outside  of  the  ure- 
thra and  penetrating  one  or  the  other  lobe  of  the  prostate,  thus  finally 
reaching  the  bladder  by  a  roundaboitt  and  most  dangerous  route. 

The  revival  of  the  Bottini  operation  affords  another  variety  of  trauma 
of  the  prostate.  TThether  the  advantages  of  the  operation  compensate  for 
its  dangers  the  future  will  tell. 

Dangers  of  Prostatic  AYounds. — As  already  suggested,  wounds  from  the 
interior  are  not  likely  to  be  followed  by  serious  results,  providing  the  in- 
jury be  limited  to  the  prostate  itself.  Lacerations  and  contusions  are  more 
dangerous  than  smooth  incisions,  save  with  respect  to  hemorrhage,  which 
is  obviously  greater  in  clean  incised  wounds,  unless  such  wounds  be  ex- 
ternal and  open.  In  considering  the  question  of  hemorrhage  from  operative 
or  accidental  wounds  of  the  prostate,  it  is  well  to  remember  that  the  region 
of  the  prostate  is  very  vascular  and  rather  difficult  of  access  for  the  applica- 
tion of  methods  of  hemostasis.  Eetention  of  urine  from  congestive  or  in- 
flammatory occlusion  of  the  urethra,  or  from  complete  or  partial  obliteration 
as  a  result  of  the  traumatism,  is  likely  to  be  an  important  consideration  in 
prostatic  injuries.  Pyogenic  infection  and  abscess,  possibly  followed  by 
urinary  fistula,  and  septic  cellulitis  are  serious  results  that  are  likely  to  occur 
in  extensive  injuries,  especially  where  drainage  is  imperfect.  The  septic 
cellulitis  may  be  limited  to  the  ano-perineal  region  and  ischio-rectal  fossa, 
or  may  extend  over  a  large  area  of  the  subcutaneous  and  intermuscular 
planes  of  cellular  tissue.  If  the  wound  extends  beyond  the  bounds  of  the 
prostate,  septic  pelvic  cellulitis  or  general  peritonitis  may  develop,  these 
being  intrinsically  fatal.  Constitutional  manifestations  of  septic  or  pathog- 
enic intoxication  may  supervene.  It  will  be  observed  that,  in  a  general  way, 
the  conditions  produced  by  and  dangers  of  prostatic  injuries  are  essentially 
the  same  as  in  traumatism  of  the  urethra  and  bladder. 

Symptoms. — There  is  nothing  characteristic  in  the  symptomatology  of 
prostatic  wounds;  in  general  they  are  similar  to  those  of  deep-urethral  trau- 
matisms. The  principal  symptom  is  urethrorrhagia,  providing  the  wound 
communicates  with  the  urethra,  and  hematuria.  If  an  open  wound  of  the 
prostate  exists  and  the  urethra  be  injitred,  the  hemorrhage  occurs  at  the 
site  of  the  injury  and  also  at  the  meatus.  Eetention  of  urine  has  already 
been  alluded  to,  and  is  an  important  factor  in  the  symptomatology  of  pro- 
static traumatism.  If  extravasation  of  blood  into  the  surrounding  tissues 
be  extensive,  a  hematoma  may  result  that  may  be  felt  by  way  of  the  rectum, 
around  which  viscns  it  may  burrow  for  a  considerable  distance.  The  local 
and  constitutional  symptoms  that  speedily  follow  serious  injuries  of  the 


NEUROSES    OF    THE    PROSTATE.  633 

prostate  are  similar  to  those  following  urethral  injuries  producing  urinary 
infiltration,  cellulitis,  or  abscess. 

Treatment. — External  operative  wounds  do  not  demand  special  con- 
sideration. In  both  internal  and  external  wounds  that  are  not  extensive, 
and  in  which  a  catheter  can  readily  be  passed,  a  full-sized  soft  instrument 
should  be  introduced  into  the  bladder  and  retained  from  three  days  to  a 
week  or  more.  Great  care  is  necessary  to  maintain  urethral  asepsis.  If 
hemorrhage  be  excessive  or  urinary  extravasation  exists,  or  there  is  reason 
to  believe  that  the  wound  of  the  prostate  is  serious,  and  in  any  case  in  which 
the  catheter  does  not  pass  readily,  a  free  perineal  section  should  be  made  and 
the  bladder  drained  by  a  large  tube.  Where  the  perineum  is  extensively 
disorganized  by  injury  and  it  is  difficult  to  find  the  proximal  end  of  the 
urethra,  suprapubic  cystotomy,  retrograde  exploration,  and  perineal  incision 
should  be  combined.  Suprapubo-perineal  drainage  should  be  instituted  in 
such  cases.  This  is  much  safer  than  prolonged  and  necessarily  hap-hazard 
search  for  the  normal  channel  via  the  perineum.  Infiltration  of  urine  de- 
mands free  incision  in  any  and  all  situations  in  which  intumescence  of  the 
tissues  is  suggestive  of  extravasated  urine.  The  incisions  can  hardly  be  too 
free  or  too  numerous,  with  due  regard  to  anatomic  dangers.  The  same 
principles  should  govern  the  management  of  urinary  abscess  and  cellulitis. 
The  early  and  free  use  of  the  knife  in  septic  cases  is  the  only  hope  of  sav- 
ing life.  The  tendency  to  asthenia,  incidental  to  the  profoundly  depressing 
influence  upon  the  sympathetic  nervous  system  produced  by  injuries  of  this 
region,  and  the  great  danger  of  toxemia,  constitute  a  direct  and  positive  in- 
dication for  free  and  liberal  supportive  measures,  dietetic  and  stimulant. 

neuroses  of  the  prostate. 

Xeueoses  of  the  Prostate  and  Eeflex  jSTeuroses  of  Prostatic 
Origin. — Considering  the  abundant  nervous  supply  of  the  prostate  and  its 
environs,  especially  its  liberal  endowment  with  sympathetic  nerve-filaments 
and  resultant  intimate  association  with  the  rectum,  bladder,  and  other 
viscera,  the  occurrence  of  nervous  phenomena  of  various  kinds  referable 
directly  or  indirectly  to  disturbance  of  the  prostate  is  not  surprising.  It  is 
true  that  many  neurotic  disturbances  which  the  author  believes  should  come 
properly  under  the  head  of  neuroses  of  the  prostate  originate  primarily  in 
demonstrable  organic  disease,  but  the  clinical  fact  remains  that  pronounced 
nervous  disturbance,  such  as  direct  or  reflex  neuralgia,  and  sometimes  con- 
siderable psychic  disturbance,  may  persist,  constituting  the  principal  source 
of  disquiet  long  after  the  primary  organic  causes  have  wholly  or  partially  dis- 
appeared. The  primary  condition  may  be  of  so  little  moment  that  there 
would  be  little  or  nothing  to  attract  the  attention  of  the  physician  were  it 
not  for  the  disproportionate  nervous  disturbance  that  results. 

In  using  the  term  prostatic  neurosis  the  author  is  well  aware  that  a  cer- 


634  DISEASES    OF   THE    PEOSTATE. 

tain  degree  of  ambiguity  must  necessarily  enter  into  the  consideration  of  the 
subject;  but  in  the  present  state  of  our  knowledge  of  disease,  from  prac- 
tical clinical  experience,  and  more  especially  to  subserve  the  purpose  of  an 
intelligent  therapy,  the  term  seems  sufficiently  clear  and  comprehensive. 

In  considering  prostatic  neuroses  there  are  several  points  to  be  borne 
in  mind,  viz.:  the  physiologic  and  anatomic  analogy  between  the  prostate 
taken  as  a  whole  and  the  uterus,  the  relation  of  the  prostate  to  urination, 
its  sexual  function,  and,  finally,  its  intimate  association  with  the  rectum, 
anus,  seminal  vesicles,  urethra,  and  bladder. 

Peostatic  Keuealgia  and  Hypeeesthesia. — ^N'euralgia  of  prostatic 
origin,  unattended  by  evidence  of  organic  disease  or  at  most  associated  with 
very  slight  organic  changes,  is  by  no  means  rare.  It  is  probable  that  a  certain 
degree  of  hyperemia  exists  in  the  majority  of  cases  of  prostatic  neuralgia; 
yet  disturbance  of  the  circulation  does  not  seem  absolutely  essential.  Hy- 
peresthesia of  the  prostate  is  usually  limited  to  its  urethral  portion  and  is 
very  frequently  met  with.  Hyperesthesia  and  neuralgia  are  often  asso- 
ciated, the  former  being  the  more  likely  to  exist  alone. 

Etiology." — The  causes  of  prostatic  neuralgia  and  hyperesthesia  are  (1) 
sexual  excesses  and  masturbation;  (2)  the  gouty  or  rheumatic  diathesis;  (3) 
traumatism  of  the  prostate,  surgical  and  accidental;  (4)  acute  or  chronic 
congestion;  (5)  acute  or  chronic  infectious  inflammation;  (6)  urethral  dis- 
ease, notably  stricture;  (7)  foreign  bodies  or  tumors  in  the  bladder;  (8) 
psychic  disturbance  with  attendant  mental  suggestion  incidental  to  (a)  ig- 
norance of  sexual  physiology  and  the  influence  of  quack  literature,  (b)  in- 
judicious and  perhaps  unnecessary  treatment  of  the  prostate,  or  (c)  the 
prolonged  duration  of  mental  disturbance  produced  by  actual  organic  dis- 
ease. The  latter  cases  are  especially  liable  to  be  associated  with  hyperemia. 
Prostatic 'catarrh  is  also  a  frequent  concomitant. 

It  would  be  difficult  to  dissociate  the  local  irritation  produced  by 
highly-acid  urine  in  gouty  and  rheumatic  patients  from  the  exaggerated 
general  nervous  sensibility  produced  by  lithemia.  Many  cases  are  found, 
however,  in  which  neuralgic  pain — referable  to  the  perineum,  anus,  neck  of 
the  bladder,  and  urethra^ — is  experienced  by  lithemic  patients  in  whom  the 
correction  of  the  irritating  acid  properties  of  the  urine  is  not  followed 
by  appreciable  benefit  until  alkaline  and  antilithic  remedies  have  modified 
the  diathesis.  The  author  has  under  observation  at  the  present  time  a  gen- 
tleman, 45  years  of  age,  who  has  been  for  some  years  annoyed  by  neuralgic 
pain  of  the  kind  described,  associated  with  intense  hyperesthesia  of  the 
prostatic  urethra.  He  is  particularly  annoyed  by  persistent  erections  at 
night,  and,  irrespective  of  the  reaction  of  the  urine,  the  act  of  urination 
gives  him  considerable  pain.  Careful  examination  of  the  bladder  and  the 
urethra  via  the  endoscope,  cystoscope,  and  mechanic  exploration  fail  to  re- 
veal any  organic  condition  that  will  explain  his  symptoms.  There  is  ap- 
parently no  disturbance  of  the  kidneys  that  might  cause  the  condition  by 


XEUKOSES    OF    THE    PEOSTATE.  635 

reflex  irritation.  The  origin  of  the  difficulty  was  probably  a  gouty  consti- 
tution associated  with  strictures  of  large  caliber.  The  latter  were  operated 
upon  some  years  ago  with  perfect  success  save  the  failure  to  ameliorate  the 
annoying  symptoms  described.  Similar  symptoms  are  often  produced  by 
rectal  or  anal  irritation:  a  condition  that  was  absent  in  this  case.  Neu- 
ralgic pain  referable  to  the  perineum  and  vesical  neck,  perhaps  radiating 
into  the  testes,  is  by  no  means  unusual  in  disease  of  the  lower  bowel.  This 
is  worthy  of  remembrance. 

Neuralgia  of  the  prostate  following  operations  upon  the  organ,  or  op- 
erations upon  the  bladder  involving  it,  is  occasionally  met  with.  The  au- 
thor has  under  observation  a  young  man  operated  through  the  perineum 
for  vesical  drainage  for  the  cure  of  obstinate  cystitis  in  whom  the  result  was 
perfect  so  far  as  the  cystitis  was  concerned,  but  the  patient  has  been  tor- 
mented ever  since  by  ano-perineal,  crural,  and  testicular  neuralgia.  There 
is  no  condition  of  the  prostate,  bladder,  or  rectum  that  explains  the  difS.- 
culty.  In  another  case,  a  man  operated  for  large-calibered  penile  stricture, 
persistent,  deep-seated,  intermittent  perineal  pain,  frequent  urination,  and 
marked  hyperesthesia  of  the  prostatic  urethra  have  existed  for  some  years. 
Careful  exploration  fails  to  detect  any  condition  that- would  explain  the 
trouble.  The  urine  is  normal.  Urethrotomy,  while  effective  in  curing  the 
stricture,  completely  failed  to  relieve  the  prostatic  neuralgia. 

Acute  and  chronic  hyperemia  of  the  prostate  are  sometimes  responsible 
for  hyperesthesia  and  neuralgia  of  the  organ,  and  in  such  cases  the  per- 
turbation of  blood-supply  is  really  the  essential  condition.  Unfortunately, 
however,  the  pain  is  not  only  the  most  prominent  feature  in  the  mind  of 
the  patient,  but  it  often  persists  in  spite  of  all  measures  tending  to  correct 
the  circulatory  disturbance.  That  a  strong  psychic  element  enters  into 
these  cases,  as,  indeed,  it  does  in  the  majority  of  cases  of  genito-urinary  dis- 
ease, is  admitted.  Psychic  disturbance  may  be  the  starting-point,  not  only 
of  vascular  disturbance  attended  with  neuralgia  and  hyperesthesia,  but  may 
produce  neurotic  phenomena  independently  of  perturbation  of  the  circula- 
tion. Prolonged  and  unnecessary  treatment  of  the  prostatic  urethra  is  not 
only  likely  to  produce  hyperesthesia  of  the  organ,  but  also  persistent  psychic 
disturbance,  possibly  hypochondriasis  or  even  melancholia,  with  or  without 
local  pain.    Hysteria  in  the  male  from  this  cause  is  not  infrequent. 

Psychoses  from  prostatic  irritation  are  very  frequent,  but  care  must 
be  taken  to  carefully  discriminate  between  cases  that  are  psychic  ab  initio 
and  those  in  which  the  psychic  element  is  simply  an  ingraft  upon  the  symp- 
toms produced  by  organic  disturbance.  Acute  or  chronic  inflammation  is 
usually  the  essential  condition,  but  many  cases  occur  in  which,  after  the 
inflammation  has  disappeared,  neuralgic  pain — referable  to  the  vesical  neck 
and  radiating  into  the  perineum,  testes,  thighs,  and  rectum — persists  in 
spite  of  all  treatment — often  perhaps  because  of  it.  Eeflex  prostatic  irrita- 
tion produced  either  by  vesical  or  urethral  disease  is  frequent.    Urethral  and 


Ij  DISEASES    OF    TJIE    PROSTATE. 

rineal  pain  associated  with  stricture  or  stone  in  the  bladder  is  a  familiar 
imple.  Stricture  occasionall}'  produces  neuralgia  referable  not  only  to 
J  prostate,  but  apparently  involving  the  entire  bladder.  A  case  at  pres- 
t  under  observation  clearly  demonstrates  this  clinical  fact.  A  gentleman, 
years  of  age,  suffered  from  pain  in  the  region  of  the  bladder  and  frequent 
cturition  for  six  or  seven  years.  He  had  been  operated  for  stricture  some 
le  prior  to  the  beginning  of  the  neuralgic  pain,  and  was  inclined  to  at- 
bute  his  trouble  to  the  urethrotomy.  Examination  revealed  several 
icture-bands  of  large  caliber  that  had  evidently  escaped  the  original  op- 
ition.  A  second  urethrotomy  was  performed  with  perfect  relief  of  the 
nptoms.  A  peculiar  feature  in  this  case  was  severe  hypogastric  pain 
enever  the  urine  was  held  for  several  hours.  This  has  completely  disap- 
jred  since  the  operation. 

The  term  prostatic  hyperesthesia  should  comprehend  the  condition  of 
called  vesical  irritability  that  has  been  described  by  some  authors  as 
euralgia  of  the  vesical  neck."  The  more  important  and  highly-sensitive 
;-ts  involved  in  the  sexual  and  urinary  functions  are  integral  parts  of  the 
)state.  The  prostatic  urethra  derives  most  of  its  importance  (save  that 
;idental  to  its  function  as  an  outlet  for  the  bladder)  from  certain  ana- 
nic  and  physiologic  peculiarities  of  the  prostate  proper.  The  elaborate 
i  highly-sensitive  nervous  supply  of  the  prostate  is  the  seat  of  urinary 
iire;  its  nervous  supply,  by  virtue  of  special  nervous  filaments  supplied 
efly  to  the  caput  gallinaginis,  is  responsible  for  the  voluptuous  sensations 
lidental  to  coitus. 

Hyperesthesia  of  the  prostate  manifests  itself  in  two  ways:  1.  Exag- 
'ated  sensibility  of  the  prostatic  urethra  to  the  pressure  of  urine  with  re- 
tant  frequent  micturition.  This  may  be  associated  with  inhibition  of  the 
iction  of  the  false  vesical  sphincter,  as  a  consequence  of  which  the  urine 
ters  the  highly-sensitive  prostatic  urethra  at  more  frequent  intervals, 
le  capacity  of  the  bladder  itself  is  probably  diminished  by  reflex  irrita- 
n  of  the  vesical  muscle.  A  careful  consideration  of  the  physiology  <»f 
cturition  readily  explains  the  so-called  vesical  irritability  resulting  from 
:)static  hyperesthesia.  2.  The  sexual  function  of  the  prostate  is  likely  to 
profoundly  disturbed  by  hyperesthesia  of  the  organ,  particularly  if  the 
:)ut  gallinaginis  be  involved.  Xocturnal  pollutions,  imperfect  erection, 
d  premature  orgasm,  or  perhaps  complete  impoteniia  cccundi  may  residt, 
5se  conditions  being  not  alwaj's  amenable  to  treatment. 

Treatment. — Xeuroses  of  prostatic  origin  constitute  a  most  emphatic 
iication  for  attention  to  genito-urinary  hygiene.  Careful  regulation  of 
it,  attention  to  the  various  emunctories,  and  careful  supervision  of  sexual 
bits  are  the  key-note  of  treatment.  Remedies  for  lithemia  are  often  essen- 
1.  Eegulation  of  the  diet,  however,  is  more  important  in  such  cases.  To- 
sco and  liquor  especially  are  to  be  interdicted.  Certain  sedative  remedies 
;  often  of  groat  value.  The  hmmids.  camphor, — or  their  combination,  cam- 


I 


HYPEKEMIA    Or    THE    PROSTATE    AND    PEOSTATORRHEA. 

plior  monobromid. — aucl  gelsemium  are  of  especial  valiie^  the  latter  rem 
being  perhaps  most  reliable.  Ergot  is  often  of  great  service.  Cold  sitz-b< 
and  enemata  are  useful.  Careful  attention  should  be  paid  to  the  condh 
of  the  bowels;  strong  cathartics  should  be  avoided  and  mild  laxatives  gi^ 
The  local  measures  of  treatment  are  numerous  and  often  unsatisfactory, 
some  cases  in  which  there  is  a  strong  psychic  element  a  cold  sound  or 
psyehrophor  is  serviceable.  Should  actual  organic  disease  of  the  prost 
urethra  exist,  however,  such  measures  may  do  harm.  In  some  cases 
nervous  organization  of  the  patient  is  such  that  local  treatment  merely 
rects  his  attention  to  the  part  and  exaggerates  his  symptoms.  In  cases  wl 
there  is  disease  of  the  mucous  membrane  of  the  prostatic  urethra,  the  j 
cious  application  of  silver  nitrate  with  the  deep-urethral  syringe  or  endosc 
is  of  value.  Deep-urethral  injections,  however,  have  probably  been  prod 
ive  of  more  damage  in  this  class  of  cases  than  in  any  other  that  could  be  n 
tioned.  Many  eases  of  neuralgia  and  hyperesthesia  of  the  prostate,  in  wl 
there  primarily  existed  no  pathologic  change  whatever  in  the  deep  uret' 
mucous  membrane,  are  treated  so  assiduously  by  deep  urethral  inject 
that  the  erroneous  diagnosis  of  disease  of  the  prostatic  urethra  is  made  g 
by  the  development  of  genuine  pathologic  conditions.  It  appears  very  il 
ical,  in  cases  in  which  careful  local  examination  and  conscientious  urinal 
fail  to  show  organic  disease,  to  treat  the  prostatic  urethra  by  frequent 
jections  of  the  silver  nitrate  to  cure  a  posterior  urethritis  existing  onl 
the  mind  of  the  practitioner.  The  readiness  with  which  the  diagnosi 
posterior  urethritis,  which  happens  to  be  the  prevailing  fad,  may  be  m 
and  the  ease  with  which  one  may  supply  himself  with  the  necessary  ins 
ments  for  deep  urethral  injection,  constitute  a  constant  menace  to  m 
patients  who  have  genito-urinary  disease,  real  or  imaginary. 

In  cases  in  which  actual  organic  disease  exists  the  first  duty  of 
surgeon  is  to  institute  appropriate  measures  for  its  removal.  "While  ] 
best  from  a  psychic  stand-point  to  impress  the  patient  with  the  radical 
suit  expected  from  the  treatment,  the  surgeon  should  remember  that  e 
after  the  primary  organic  difficulty  has  been  cured  the  neurosis  may  rem 
The  experience  derived  from  the  removal  of  the  original  cause  in  r( 
neuralgias  in  other  situations  has  been  that  the  neuralgia  frequently 
sists  in  spite  of  a  radical  operation  for  the  removal  of  the  offending  co 
tion.  The  same  clinical  observation  applies  to  neuralgia  and  hyperesth 
of  the  prostate. 

HYPEREMIA    OF    THE    PROSTATE    AXD    PROSTATOREHEA. 

Hyperemia.— -The  line  of  demarkation  between  prostatic  hypere 
and  inflammation  is  often  rather  indefinite.  From  a  pathologic,  and  n 
especially  from  a  clinical,  stand-point,  there  are,  nevertheless,  many  c 
of  prostatic  disease  that  are  essentially  active  or  passive  hyperemia  ra 


638  DISEASES    OF    THE    PROSTATE. 

than  inflammation.  Tliat  hyperemia  predisposes  to,  and  is  likely  to  termi- 
nate in,  true  inflammation  is  well  understood.  Especially  is  this  true  of 
prostatic  diseases  involving  local  circulatory  disturbance.  This  proposition 
is  therefore  taken  for  granted  as  a  preliminary  to  the  discussion  of  pro- 
static hyperemia.  In  perhaps  the  majority  of  cases  of  prostatic  disease  the 
diagnosis  of  prostatitis,  acute  or  chronic,  is  made  and  passes  without  ques- 
tion. That  no  harm  thereby  results  in  the  majority  of  cases  is  simply  be- 
cause the  principles  of  treatment  are  essentially  the  same  in  both  conditions. 
In  some  cases,  however,  a  true  appreciation  of  the  conditions  present  would 
be  of  direct  benefit  to  the  patient,  as  in  certain  cases  of  passive  congestion 
from  venous  obstruction.  Measures  that  relieve  passive  hyperemia  are  likely 
to  prevent  the  development  of  true  inflammation. 

Etiology. — Active  prostatic  hyperemia  has  its  point  of  departure,  as  a 
rule,  in  perturbation  either  of  the  sexual  function  or  of  the  physiologic  act  of 
micturition.  The  prostate  is,  from  time  to  time,  the  seat  of  physiologic  hy- 
peremia, as  is  true  of  all  glandular  organs.  This  attends  sexual  excitement, 
hoRvever  such  excitement  may  be  produced.  Under  normal  conditions  the 
circulation  resumes  its  usual  status  as  soon  as  the  excitement  ceases.  Its 
return  to  a  normal  circulatory  state  is  still  more  rapid  when  the  sexual  func- 
tion has  been  naturally  performed.  Prolonged  sexual  excitement  without 
gratification  is  the  most  prolific  source  of  prostatic  hyperemia.  Frequent 
masturbation  and  sexual  excess  will  also  produce  it.  The  periods  of  rest  be- 
tween the  acts  of  ejaculation  are  so  short  that  the  circulation  cannot  regain 
its  normal  equilibrium.  Sexual  excess  and  masturbation  are  even  more 
potent  in  the  production  of  pathologic  hyperemia  when  associated  with 
erotic  mentality,  alcohol,  high  living,  and  a  gouty  or  rheumatic  diathesis. 
If  hyperemia  be  long  continued,  subacute  or  chronic  inflammation  will 
probably  supervene. 

The  relation  of  sexual  excitement  to  prostatic  disease  demands  great 
consideration.  It  should  be  understood  that  physical  continence  may  be 
associated,  so  to  speak,  with  mental  incontinence,  with  a  resulting  pro- 
static hyperemia  that  may  produce  both  functional  and  organic  disturbance. 
The  importance  of  avoiding  sexual  stimuli,  psychic  and  physical,  cannot  be 
too  strongly  presented  in  the  management  of  all  prostatic  and  vesical  dis- 
eases. 

More  or  less  prostatic  hyperemia  is  probably  almost  always  present  in 
urethral  and  bladder  disease,  acute  or  chronic,  being  due  not  only  to  in- 
flammation of  the  vesico-urethral  mucous  membrane  per  se,  but  also  to  fre- 
quent micturition  produced  by  irritation  of  the  vesical  neck.  The  termina- 
tion of  the  act  of  micturition  is  characterized  by  reflex  spasm  of  the  cut-off 
muscle,  which  is  greatly  exaggerated  by  hyperesthesia  of  the  posterior 
urethra  incidental  to  inflammation  or  reflex  irritation  of  the  part.  So  ex- 
aggerated is  the  spasmodic  contraction  of  the  physiologic  cut-off  that  actual 
traumatism  of  the  prostate  results.    There  is  marked  disturbance  of  the  cir- 


HYPEEEMIA    OF    THE    PEOSTATE    AND    PEOSTATOEEHEA.  639 

culation  and  not  only  active  hyperemia,  but  lessened  power  of  resistance  of 
both  glandular  and  muscular  structure  to  infection. 

Irritative  and  inflammatory  affections  of  the  lower  bowel  produce  re- 
flex irritation  of  the  vesical  neck  with  associated  prostatic  hyperemia.  The 
hyperemia  and  associated  spasm  may  be  so  severe  as  to  produce  retention. 
This  is  observed  after  operations  about  this  part  and  in  inflamed  hemor- 
rhoids. Eectal  tenesmus,  as  seen  in  certain  cases  of  dysentery  and  acute 
proctitis,  is  apt  to  produce  similar  conditions  affecting  the  prostate  and 
vesical  neck.  In  chronic  disease  of  the  lower  bowel,  such  as  polypi,  stricture, 
tumors,  and  particularly  hemorrhoids,  passive  congestion  of  the  prostate  re- 
sults from  venous  obstruction.  The  author  has  observed  well-marked  pro- 
static enlargement  associated  with  stricture  of  the  rectum  and  hemorrhoids 
that  has  disappeared  after  an  operation  upon  the  lower  bowel.  Constipa- 
tion, excessive  horseback-riding,  and  cycling  are  sometimes  efficient  causes 
of  prostatic  hyperemia. 

Hyperemia  of  the  prostate  is  a  feature  of  all  cases  of  strangury  pro- 
duced by  drugs.  Cantharides,  turpentine,  and,  it  is  said,  the  various  bal- 
samic preparations  may  produce  this  condition.  Prostatic  hyperemia  rarely, 
if  ever,  goes  on  to  acute  inflammation  idiopathically.  Instrumental  inter- 
ference with  associated  trauma  and  sepsis,  or  mixed  infection  from  posterior 
urethritis,  is  usually  necessary  to  precipitate  acute  inflammation.  Obstruct- 
ive urethral  disease  is  likely  to  produce  more  or  less  marked  prostatic  hy- 
peremia. Urethral  strictures  of  small  caliber  are  usually  associated  with 
more  or  less  prostatic  engorgement.  Large-calibered  penile  strictures  may 
produce  prostatic  hyperemia  reflexly,  even  where  there  is  no  appreciable 
obstruction  to  urination.  The  slightest  contraction  in  the  bulbo-mem- 
branous  region,  from  the  close  association  of  its  nervous  and  vascular  sup- 
ply with  that  of  the  prostate,  is  likely  to  produce  circulatory  disturbance  of 
the  latter  structure. 

Hyperemia  of  the  prostate  may  become  chronic.  The  chronic  form  is 
usually  passive,  and  most  frequently  associated  with  constipation  and  un- 
gratifled  sexual  desire.  Sexual  excitement  is  the  most  important  factor 
in  its  production,  and  is  especially  likely  to  exist  in  masturbators,  in 
whom  it  is  characterized  by  the  escape  of  prostatic  fluid  at  various  times. 
The  affection  is  usually  supposed  by  the  patient  to  be  spermatorrhea,  while 
by  the  profession  at  large  most  eases  are  classified  as  prostatorrhea.  The 
prostatic  congestion  causes  hypersecretion,  and  probably  relaxation  of  the 
mouths  of  the  prostatic  ducts.  The  condition  might  be  classified  as  pro- 
static catarrh  were  it  not  for  the  quite  general  association  of  this  term  with 
true  inflammation.  Follicular  prostatitis  as  described  by  most  writers  im- 
plies this  result  of  hypersecretion,  and  to  the  author  appears  to  be  a  mis- 
nomer. The  principal  disturbances  from  this  form  of  prostatic  disease  are 
of  a  psychic  rather  than  physical  character. 

Whether  or  not  chronic  hyperemia  of  the  prostate  from  sexual  causes 


640  DISEASES    OF    THE    PROSTATE. 

may  be  the  foimdation  of  hypertrophy  of  the  organ  in  after-life  has  been 
the  subject  of  much  contention.  The  author  inclines  to  the  afhrmative,  as 
will  hereafter  appear. 

Symptoms. — One  of  the  most  characteristic  symptoms  of  prostatic  hy- 
peremia is  a  sense  of  fullness  in  the  perineum  and  a  Yoluptuous  sensation 
as  of  impending  orgasm.  There  is  likely  to  be  a  sensation  of  fullness  in 
the  rectum  with  possibly  erotic  sensations  and  more  or  less  tenderness 
during  evacuation  of  the  bowel.  An  urgent  desire  to  urinate  is  almost 
invariably  excited  by  defecation.  There  may  be  considerable  prostatic  en- 
gorgement without  much,  if  any,  increase  in  the  frequency  of  micturition. 
If,  however,  the  point  of  departure  be  direct  or  reflex  irritation  or  inflam- 
mation of  the  posterior  urethra,  frequent  and  painful  micturition  is  an 
inevitable  result.  Even  in  cases  in  which  micturition  is  not  increased  in 
frequenc}',  the  patient  will  very  likely  complain  of  some  pain  and  a  bruised 
sensation  in  the  perineum  following  the  act.  If  the  hyperemia  be  long  con- 
tinued, "'jDrostatorrhea''  is  likely  to  supervene  as  a  consequence  of  hyper- 
secretor}'  activity  of  the  prostatic  glands.  In  some  cases  the  floor  of  the 
prostatic  urethra  becomes  so  hypersensitive  that  frequent  seminal  emissions 
occur.  Eusty  or  bloody  semen  is  occasionally  observed;  but,  as  a  rule,  this 
symptom  is  indicative  of  seminal  vesiculitis.  Pain  during  the  paroxj-smal 
spasm  of  seminal  ejaculation  is  a  frequent  symptom.  On  the  other  hand, 
many  patients  state  that  coitus  is  beneficial.  In  such  cases  it  is  very  safe 
to  conclude  that  the  condition  of  the  prostate  is  one  of  simple  hyperemia. 
Even  in  such  cases,  however,  it  is  not  unusual  for  the  patient  to  experience 
only  temporary  relief  from  coitus.  Often-repeated  indulgence  results  in 
aggravation  of  the  symptoms.  Eectal  examination  may  elicit  some  fullness 
and  tenderness  of  the  prostate.  This  is  not  always  present,  as  there  may 
be  quite  a  degree  of  passive  hyperemia  without  much  increase  in  the  size 
of  the  'prostate.  This  sj^mptom  is  Cjuite  apt  to  be  unreliable  because  of  the 
variability  of  the  size  of  the  prostate  as  felt  per  rectum  and  the  varying  de- 
gree of  digital  expertness  in  rectal  examination.  Passive  hyperemia  of  the 
prostate  associated  with  circulator}'  disturbance  in  the  lower  bowel,  or  de- 
pendent upon  a  gout}''  or  rheumatic  diathesis,  is  occasionally  associated  with 
hematuria.  The  author  has  observed  a  number  of  cases  of  hematuria  with 
the  expulsion  of  the  characteristic  fusiform  clot  found  in  prostatic  hemor- 
rhage in  which  no  cause  could  be  determined  other  than  passive  prostatic 
congestion  which  attention  to  the  assumed  etiologic  factors  speedily  relieved, 
measures  to  relieve  portal  congestion  having  been  especially  efficacious. 
This  is  worthy  of  consideration  in  cases  of  hematuria  of  obscure  origin. 

Peostatorehea. — A  frequent  symptom  of  chronic  hyperemia  of  the 
prostate  is  a  discharge  of  its  characteristic  secretion  from  the  urethra.  This 
is  favored  by  sexual  excitement,  erotic  ideas  being  often  sufficient  to  produce 
it.  Under  such  circumstances  it  is  associated  with  more  or  less  urethral  se- 
cretion, which  escapes  during  the  excitement,  while  the  prostatic  secretion 


HTPEEEMIA   OF    THE    PEOSTATE    AND    PEOSTATOEEHEA.  641 

afterward  comes  away  with,  the  urine.  It  is  most  frequently  observed  during 
straining  at  stool,  and  sufficient  secretion  may  escape  with  the  urine  to  pro- 
duce an  appreciable  deposit  in  this  fluid  on  standing.  Very  often  no  prostatic 
discharge  is  noticeable  excepting  at  the  termination  of  micturition,  when, 
according  to  the  patient's  story,  the  urine  appears  to  be  decidedly  milky. 
These  patients  are  the  most  likely  of  all  to  become  victims  of  the  quack; 
they  constitute  by  far  the  larger  proportion  of  cases  of  alleged  spermator- 
rhea. Associated  with  the  local  difficulty  is  more  or  less  hyponchondria, 
perhaps  verging  upon  melancholia.  The  patient  occupies  himself  very  in- 
dustriously in  magnifying  every  symptom,  real  or  imaginary,  of  which  he 
may  chance  to  be  the  victim.  His  unstable  psychic  condition  explains  the 
profound  influence  that  quacks  and  quack  literature  are  likely  to  have  upon 
him.  Associated  with  the  so-called  prostatorrhea  may  be  more  or  less  ves- 
ical irritation,  largely  neurotic  in  character,  and  perhaps  neuralgic  pains  in 
the  urethra,  perineum,  groins,  and  thighs.  The  majority  of  patients  com- 
plain of  pain  in  the  back  as  the  most  prominent  symptom  aside  from  the 
urethral  discharge. 

Whenever  fluid  escapes  from  the  meatus  during  the  intervals  of  mic- 
turition, excepting  in  the  act  of  defecation,  some  morbid  condition  of 
the  anterior  urethra  is  superadded  to  the  prostatic  hyperemia.  The  pro- 
static fluid  cannot  escape  unless  the  true  sphincter  vesicae — i.e.,  the  mem- 
branous urethra  and  its  muscular  investments — is  relaxed  physiologically, 
or  the  prostate  is  mechanically  squeezed  by  the  perineal  muscles  and  the 
passage  of  hardened  feces.  The  fluid  that  escapes  during  sexual  excitement 
usually  consists  of  urethral  secretion.  In  cases  of  simple  chronic  hyperemia 
of  the  prostate  the  prostatic  discharge  does  not  contain  inflammatory  ele- 
ments, being  made  up  almost  entirely  of  prostatic  secretion,  mucus,  and  some 
effete  epithelial  cells.  There  may  be  present,  especially  after  sexual  excite- 
ment, a  certain  number  of  seminal  elements  that  have  escaped  from  the  over- 
distended  vesiculas  seminales.  The  escape  of  semen  into  the  prostatic  urethra 
is  favored  by  relaxation  or  patulousness  of  the  mouths  of  the  ejaculatory 
ducts,  and  is  often  immediately  induced  by  straining  at  stool.  The  seminal 
elements  are  scanty  and  by  no  means  a  constant  or  necessary  symptom. 
Rarely,  indeed,  are  they  sufficiently  abundant  to  justify  a  diagnosis  of  sper- 
matorrhea. No  matter  how  few  in  number  they  may  be,  however,  they  are 
hailed  with  delight  by  the  quack  and  are  often  assigned  undue  importance 
even  by  honest  practitioners. 

Treatment. — The  first  principles  of  treatment  of  prostatic  hyperemia 
involve  all  of  the  rules  of  genito-urinary  hygiene,  a  subject  already  ex- 
haustively discussed.  Briefly,  the  urine  should  be  rendered  unirritating  by 
the  administration  of  bland  fluids,  of  which  distilled  water  or  the  various 
saline  mineral  waters  may  be  taken  as  the  type.  Alkaline  remedies  may  be 
administered  where  simpler  measures  are  not  sufficient  to  neutralize  urinary 
acidity.     The  diet  should  be  unstimulating.     All  sources  of  sexual  exeita- 


643  DISEASES    OF   THE    PEOSTATE. 

tion,  both  psychic  and  physical,  should  be  removed.  Exercise  should  be  re- 
stricted and,  if  necessary,  prohibited  altogether.  Athletic  feats,  cycling, 
horseback-riding,  and  climbing  are  particularly  to  be  enjoined.  The  author 
would  especially  call  attention  to  climbing  exercises  as  practiced  by  young 
lads  and  some  athletes  as  especially  injurious.  The  danger  of  the  condi- 
tion's becoming  chronic  should  be  impressed  upon  the  patient.  Instru- 
mentation of  the  urethra  is,  in  general,  to  be  avoided  in  acute  hyperemia. 

Numerous  internal  remedies  are  more  or  less  serviceable  in  prostatic 
congestion.  Mercurial  and  saline  cathartics  and  laxatives  are  especially 
beneficial  b}'  relieving  hepatic  obstruction,  thus  indirectly  removing  ob- 
struction to  the  pelvic  circulation.  Ergot  and  gossypium  are  of  undoubted 
value,  directly  tending  to  correct  the  circulatory  disturbance.  Sexual  ex- 
citement is  best  combated  by  the  bromids  in  combination  with  gelsemium. 
Monobromid  of  camphor,  hyoscyamus,  and  other  anaphrodisiacs  are  likely 
to  be  of  service.  Suppositories  of  ice  and  enemata  of  cold  water  are  often 
valuable,  cold  sitz-baths  being  an  excellent  adjuvant.  In  prostatic  hy- 
peremia dependent  upon  ano-rectal  or  vesical  disease,  attention  should,  of 
cotiTse,  be  given  to  the  primary  condition. 

In  cases  of  chronic  prostatic  hyperemia  associated  with  so-called  pros- 
tatorrhea  special  attention  should  be  paid  to  the  psychic  disturbances  pres- 
ent. Earely,  indeed,  are  such  cases  presented  to  the  reputable  practitioner 
before  a  number  of  quacks  have  been  consulted.  The  patient  is  thoroughly 
convinced  that  he  has  spermatorrhea  with  an  allied  train  of  serious  nervous 
disturbances,  and  last,  but  not  least,  he  believes  himself  impotent.  In- 
struction in  sexual  physiology  and  hygiene  is  absolute  necessary  for  this 
class  of  patients.  Particularly  must  they  be  impressed  with  the  fact  that 
they  are  not  losing  semen  in  the  urine,  else  all  of  our  efforts  will  be  set  at 
naught  by  their  morbid  psychic  state.  By  far  the  larger  proportion  of 
cases  suffer  from  constipation.  The  relief  of  this  condition  usually  causes 
the  prostatorrhea — the  most  prominent  symptom,  in  the  opinion  of  the 
patient — to  disappear.  Ergot  and  the  bromids  are  exceedingly-useful  in- 
ternal remedies.  Hamamelis  and  hydrastis  are  serviceable  from  their  known 
influence  over  unstriated  muscular  fiber  and  incidentally  by  controllijig  vas- 
cular supply.  Tonics — such  as  preparations  of  strychnin,  iron,  and  arsenic, 
and  the  mineral  acids — are  very  likely  to  be  useful  in  this  class  of  cases. 
The  occasional  passage  of  a  cold  sound  or  the  psychrophor  is  a  valuable  local 
measure.  The  effect  of  instrumentation  is,  to  a  certain  extent,  moral,  but 
its  benefits  are  none  the  less  marked.  Its  physical  effect  is  probably  the 
restoration  of  local  vascular  tone  and  relief  of  nervous  irritability.  Cold 
sitz-baths  and  injections  of  cold  water  into  the  rectum  constitute  a  valu- 
able adjuvant.  Counter-irritation  to  the  perineum  is  likely  to  be  beneficial. 
The  application  of  astringents  to  the  prostatic  urethra  may  be  alternated 
with  the  insertion  of  the  steel  sound.  The  silver  nitrate  in  mild  solutions, 
tannic  acid,   and  hydrastin   muriate  are   all   serviceable   drugs.     Soluble 


ACUTE    PROSTATIC    INFLAMMATION   AND    SUPPUEATION.  643 

bougies  containing  astringents  are  sometimes  of  service.  Prostatic  massage 
is  often  a  most  reliable  measure.  The  local  treatment  in  prostatic  hy- 
peremia associated  with  so-called  prostatorrhea  is  very  similar  to  that  of 
chronic  follicular  prostatitis  in  which  escape  of  prostatic  secretion  is  also  a 
symptom. 

ACUTE   PEOSTATIC    INFLAMMATION   AND    SUPPUEATION. 

Acute  Peostatitis. — Acute  prostatitis  is  one  of  the  most  serious  and 
painful  of  the  acute  affections  of  the  genito-urinary  system.  The  infection 
that  most  often  gives  rise  to  it  is  so  prevalent  that  the  disease  is  quite  fre- 
quent. In  a  general  way^  while  acvite  prostatitis  may  or  may  not  be  preceded 
by  predisposing  hyperemia  of  greater  or  less  duration,  the  disease  is  rarely 
a  primary  affection  excepting  it  be  of  traumatic  or  chemic  origin  or  the 
result  of  pyogenesis  produced  by  constitutional  infection  such  as  exists  in 
variola  and  parotiditis.  As  usually  met  with,  it  is  a  complication,  not  a 
primary  disease. 

The  profound  local  and  constitutional  disturbances  existing  in  a  large 
proportion  of  cases  of  acute  prostatitis,  especially  in  those  forms  in  whicli 
suppuration  results,  are  entirely  disproportionate  to  the  size  and  physio- 
logic importance  of  the  organ  involved.  The  affected  part,  however,  is  ex- 
ceedingly sensitive  from  its  abundant  supply  of  general  and  special  sensory 
nerve-filaments,  and  is  of  great  importance  because  of  its  abundant  sym- 
pathetic nerve-supply  and  consequent  intimate  relation  with  the  various 
organs  involved  in  the  functions  of  organic  life.  In  this  respect  it  resembles 
its  co-laborer  in  the  generative  function,  the  testis.  Like  the  latter  organ, 
it  is  surrounded  by  a  tough  resisting  capsule,  and  in  addition  by  an  en- 
vironment of  firm,  resisting  structures.  Because  of  this  anatomic  arrange- 
ment the  organ  does  not  yield  readily  to  the  pressure  of  exuded  inflamma- 
tory products  or  exaggerated  blood-supply.  This,  in  connection  with  the 
exceedingly  sensitive  and  abundant  nerve-filaments,  is  sufficient  to  explain 
the  severe  pain,  nervous  depression,  and  other  constitutional  disturbances 
in  prostatitis.  The  same  anatomic  conditions,  in  connection  with  the  close 
proximity  of  the  affected  organ  to  the  rectum,  explain  the  disturbance  ref- 
erable to  the  latter  viscus  in  acute  prostatic  inflammation. 

Etiology. — The  causes  of  acute  prostatitis,  as  outlined  by  some  authors, 
are  rather  complex,  presenting  many  elements  of  impracticality  and  con- 
fusion. Practical  clinical  experience  shows  that,  while  many  predisposing 
elements  demand  consideration,  acute  prostatitis  is  due,  in  the  majority  of 
cases,  to  causes  of  quite  common  character.  Thus,  nearly  all  cases  are  due 
to  extension  of  acute  urethritis,  usually  gonorrheal.  Other  factors  are  to 
be  taken  into  consideration,  it  is  true,  in  suppurative  cases,  because  of  the 
clinical  fact  that  in  by  far  the  larger  proportion  of  cases  of  acute  prosta- 
titis suppuration  does  not  follow.  The  author  bases  this  broad  assertion 
upon  the  view  that  in  the  larger  proportion  of  cases  of  acute  inflammation 


644 


DISEASES    OF    THE    PEOSTATE. 


of  the  prostate  the  process  is  limited  to  the  glandular  structures  of  the  organ 
and  partakes  of  the  same  characters  as  the  original  gonorrheal  infection, 
with  certain  modifications  due  to  anatomic  and  physiologic  peculiarities  of 
the  affected  part.  Mechanic  interference  with  the  prostate  in  the  treat- 
ment of  acute  or  chronic  bladder  disease,  or  in  vesical  exploration,  is  re- 
sponsible for  most  of  the  remaining  cases.  Even  here  we  have  gonorrheal 
or  other  urethral  infection  as  the  principal  etiologic  factor,  the  instrument 
used  or  the  abrasion  produced  by  it  acting  merely  as  a  carrier  of  infection, 
on  the  one  hand,  or  a  locus  minoris  resistentice,  on  the  other.  Experience 
has  shown  that  in  every  case  of  urethral  disease,  acute  or  chronic,  more  par- 
ticularly in  the  acute,  the  patient  is  constantly  liable  to  acute  prostatitis. 
In  view  of  the  careless,  routine,  and  often  overvigorous  treatment  of  gon- 
orrhea, to  say  nothing  of  the  vicious,  self-imposed  unhygienic  conditions  of 
the  patient,  it  is  surprising  that  prostatic  complications  do  not  occur  in  nearly 
every  case  of  gonorrheal  infection.  That  patients  with  virulent  specific 
urethritis  should  escape  prostatic  complications  is  remarkable,  when  we  con- 
sider the  high  degree  of  infectiousness  of  the  various  microbial  organisms 
found  in  that  typically-mixed  infection,  gonorrhea.  Acute  prostatitis  may 
be  developed  by  trifling  causes  during  the  course  of  a  gonorrhea.  The 
jcause  may  consist  of  ill-advised  attempts  to  cure  the  disease  or  misconduct 
on  the  part  of  the  patient.  It  is  especially  liable  to  follow  sexual  indiscre- 
tions or  excitement.  Alcoholic  and  dietetic  excesses,  and  overexertion  play 
an  important  role  in  developing  this  complication. 

The  following  rather  simple  classification  may  give  a  somewhat  clearer 
insight  into  the  etiology  of  acute  prostatitis  than  the  foregoing  remarks. 

ETIOLOGY    OF    ACUTE    PEOSTATITIS. 

/  C  Gouty  and  rheumatic  diatheses. 

General  I  Alcoholic  and  dietetic  excesses. 
I  Exposure  to  cold. 


Predisposing  causes 


Highly-acid  urine. 

Hyperemia  from  whatever  cause. 

Acute  or  chronic  urethritis. 

Stricture. 

Chronic  prostatic  disease. 

Cystitis  or  other  vesical  disease. 
Local      <  Vesical  calculi. 

Eectal  and  anal  disease. 

Portal  obstruction. 

Constipation  or  diarrhea. 

Overexertion,  and  such  forms  of  ex- 
ercise as  bicycling  and  horseback- 
ridincf. 


ACUTE    PKOSTATIC    IXFLAMMATIOX    AND    SUPPUEATIOX.  645 

Gonorrhea  and  its  congeners^by  direct  exten- 
sion, or  indirectly  by  absorption  of  in- 
fections materials — i.e.,  germs  or  their 
products. 

Traumatism.  Surgical  or  accidental,  chemic  or 
Exciting  causes  ^  mechanic. 

Sexual  indulgence. 

Chemic  irritation. 

Vesical  or  prostatic  calculi. 

Transportation  of  infectious  material  by  deep 
injections  or  instrumentation. 

Broadly  speaking,  by  far  the  majority  of  cases  of  acute  prostatitis  are 
due  to  infection  in  some  form.  This  being  accepted,  it  is  obvious  that  many 
of  the  causes  outlined  in  the  above  table  are  secondary  and  subordinate  to 
infection.  If  we  add  to  the  cases  produced  by  infection  the  relatively  much 
smaller  number  of  cases  produced  by  mechanic  and  chemic  violence,  we 
have  practically  covered  the  etiology  of  acute  prostatitis.  It  is  to  be  un- 
derstood also  that  in  many  instances  chemic  and  traumatic  injuries  of  the 
prostate  produce  inflammation  solely  by  carrying  infection  or  by  opening 
up  avenues  for  the  absorption  of  infectious  material.  It  is,  of  course,  dif- 
ficult to  separate  these  cases  from  those  in  which  the  inflammation  is  im- 
mediately due  to  traumatic  or  chemic  causes.  It  is  safe  to  assume,  however, 
that,  in  those  cases  in  which  suppuration  occurs,  chemic  or  traumatic  in- 
jury to  the  prostate,  if  it  exists  at  all,  is  a  factor  subordinate  to  infection. 

Exposure  to  cold  unassociated  with  a  gouty  or  rheumatic  diathesis  is 
not,  in  the  author's  opinion,  a  sufflcient  cause  for  acute  prostatitis,  unless 
infection  exist.  That  profound  disturbance  of  the  circulation  of  the  pros- 
tate may  result  from  chilling  of  the  surface  of  the  body,  particularly  of  the 
lower  extremities,  is  admitted.  But  that  this  will  cause  acute  prostatitis 
where  some  source  of  infection  is  not  present  cannot  be  accepted  in  the 
light  of  our  present  knowledge  of  the  germ-origin  of  disease.  If,  however, 
infection  of  the  urethra,  prostate,  or  bladder  exists,  the  circulatory  disturb- 
ance produced  by  exposure  may  lessen  resistance  to  germ-infection  on  the 
part  of  the  prostate,  with  consequent  acute  prostatitis,  with  or  without  ab- 
scess. Cases  are  frequent  in  which  patients  presumably  have  had  no  in- 
fectious disease  of  the  genito-urinary  tract,  but  in  whom  irritation  of  the 
vesical  neck  results  from  exposure  to  cold.  It  will  be  found,  however,  that 
in  such  eases  there  usually  exists  a  more  or  less  marked  tendency  to  rheu- 
matism or  gout.  Many  cases  of  so-called  prostatitis  consist  merely  in  irri- 
tation of  the  mucous  membrane  of  the  prostatic  urethra  due  to  an  excess 
of  uric-acid  crystals  in  the  urine  incidental  to  chilling  of  the  surface  of  the 
body.  Such  cases  are  frequently  diagnosed  as  acute  prostatitis.  In  the 
majority  of  them,  however,  not  only  is  there  no  inflammation  of  the  pros- 


646  DISEASES    OF    THE    PEOSTATE. 

tate  proper,  but  no  inflammatiorL  even  of  the  prostatic  urethra;  the  condi- 
tion is  merely  local  irritation  of  highly-sensitive  nerve-filaments  due  to  dis- 
proportionate increase  of  the  solid  constituents  of  the  urine,  involving  irri- 
tating erj^stals  of  uric  acid  and  possibly  calcium  oxalate. 

The  prolonged  contact  of  the  perineum  with  a  cold,  damp  surface  is 
said  to  cause  acute  prostatitis.  While  this  may  be  a  secondary  cause,  it  is 
probably  incapable  of  inducing  acute  inflammation  unless  there  is  some 
source  of  infection.  The  gouty  and  rheumatic  diatheses,  either  alone  or 
associated  with  exposure,  may  develop  prostatic  irritation  and  possibly  acute 
prostatitis  in  cases  in  which  infection  already  exists.  Gout  and  rheuma- 
tism not  only  produce  aberration  of  the  quality  and  quantity  of  urinary 
solids,  and  alteration  of  urinary  reaction,  but  also  intrinsic  irritability  of 
nervous  and  vascular  structures,  by  virtue  of  which  they  react  more 
promptly  and  markedly  to  sources  of  irritation. 

It  is  obvious  that  an  individual  exposed  to  psychic  or  physical  causes 
of  sexual  excitement  is  especially  predisposed  to  acute  prostatitis  in  the  pres- 
ence of  infectious  genito-urinary  disease.  It  is  certain  that,  if  this  predis- 
posing cause  could  be  eliminated  in  the  majority  of  cases  of  acute  or  chronic 
genito-urinary  disease,  the  proportion  of  cases  in  which  a  complicating 
prostatitis  develops  would  be  materially  reduced.  Acute  or  chronic  ure- 
thral disease  is  a  constant  menace  to  the  prostate.  Stricture  is  especially 
worthy  of  consideration  in  this  regard.  Acute  or  chronic  urethral  inflam- 
mation leads  to  acute  prostatitis  through  comparatively  trifling  exciting 
causes.  Chronic  prostatic  disease,  especially  those  forms  in  which  a  focus 
of  infection  exists  in  the  prostatic  urethra  or  bladder,  is  very  liable  to  be 
complicated  by  acute  prostatitis.  Especially  is  this  true  if  traumatic  inter- 
ference, in  the  form  of  violent  or  often-repeated  catheterization,  be  added 
as  an  exciting  cause.  Acute  prostatitis  or  paraprostatitis  is  a  rather  fre- 
quent complication  of  prostatic  hypertrophy.  What  has  been  said  of  acute 
and  chronic  disease  of  the  prostate  also  applies  to  cystitis.  The  infectious 
products  of  vesical  inflammation  may,  at  any  time,  under  the  exciting  in- 
fluence of  traumatism  or  through  the  medium  of  a  secondary  infection  of 
the  prostate  and  prostatic  urethra,  produce  acute  prostatitis. 

Eectal  and  anal  disease  exert  so  profound  an  influence  over  the  vas- 
cular and  nervous  supply  of  the  prostate  that  their  importance  as  etiologic 
factors  predisposing  to  acute  inflammation  of  the  organ  is  readily  under- 
stood. Ph5^sical  exertion — particularly  that  involved  in  walking,  running, 
lifting,  bicycling,  and  other  forms  of  athletic  exercises  in  which  more  or  less 
strain  is  brought  to  bear  upon  the  perineum — tends  to  produce  irritability 
and  hyperemia  of  the  prostate,  in  the  presence  of  which  any  source  of  in- 
fection is  apt  to  lead  to  acute  inflammation  of  the  organ. 

In  by  far  the  majority  of  cases  of  acute  prostatitis  there  exists  some 
urethral  source  of  infection,  either  patent  or  obscure,  as  a  direct  cause  of 
the  acute  inflammation.     True  suppurative  inflammation  of  the  urethra  is 


ACUTE    PROSTATIC    INFLAMMATION   AND    SUPPUEATION.  647 

not,  however,  absolutely  necessary  in  order  that  infection  of  the  prostate  by 
germs  or  germ-products  may  occur.  Thus  the  infection  may  consist  of  the 
products  of  decomposing  urine,  or  the  secretions  of  urethral  or  prostatic 
catarrh  confined  behind  some  obstruction  of  the  canal,  such  as  is  afforded 
by  prostatic  hypertrophy  or  stricture.  The  cause  is  most  likely  to  be  a 
recent  gonorrhea  of  acutely-virulent  type,  but  the  infective  inflammation 
may  be  subacute  or  chronic.  Simple  urethritis,  acute  or  chronic,  presents 
a  secretion  teeming  with  germs  and  their  products  that  may  at  any  time 
produce  acute  inflammation  of  the  prostate.  It  must  be  remembered,  in 
this  connection,  that  it  is  probably  the  mixed  character  of  the  gonorrheal 
infection  that  is  responsible  for  the  cases  in  which  suppuration  of  the  pros- 
tate or  periprostatic  tissues  occurs.  Laying  aside  acute  follicular  prostati- 
tis,— i.e.,  posterior  urethritis  occurring  in  the  course  of  acute  or  chronic 
gonorrhea, — the  pus-microbe  and  its  products  are  responsible  for  prostatic 
complications.  It  is  safe  to  assert  that  in  most  cases  of  acute  prostatitis 
an  area  of  bacterial  infection  exists  in  the  deep  urethra.  This  may  consist 
of  acute  suppurative  or  chronic  infective  inflammation  of  the  bulbous  or 
bulbo-membranous  region.  In  the  presence  of  such  conditions  the  slightest 
traumatism  or  the  occurrence  of  active  hyperemia  may  at  any  time  produce 
acute  inflammation  of  the  prostate. 

One  of  the  most  frequent  causes  is  mechanic  disturbance  of  the  pros- 
tate in  sexual  intercourse.  During  the  venereal  orgasm  the  muscular  tis- 
sues of  the  perineum,  and  incidentally  of  the  prostate,  act  somewhat  like 
the  bulb  of  the  ordinary  soft-rubber  syringe.  The  spasmodic  contraction 
incidental  to  the  orgasm  alternates  with  relaxation,  during  which  the  deep 
perineal  muscles  and  prostate  exert  an  aspirating  effect  upon  the  urethra. 
The  superfluous  semen  is  drawn  back  into  the  deep  urethra  preparatory 
to  the  occurrence  of  the  final  spasmodic  muscular  contraction  by  means  of 
which  the  last  few  drops  of  semen  are  to  be  expelled.  During  the  back- 
ward aspiration  of  the  semen  into  the  deep  urethra  any  infectious  materials 
that  may  be  present  in  the  anterior  portion  of  the  canal  are  forcibly  drawn 
into  the  deeper  parts,  where  they  produce  acute  inflammation.  This,  while 
primarily  an  acute  follicular  prostatitis,  may  be  followed  at  any  time,  per- 
haps within  a  very  short  period,  by  acute  diffuse  inflammation  and  possibly 
abscess.  Patients  developing  acute  prostatitis  in  the  course  of  gonorrhea 
often  confess  sexual  indulgence  or  a  nocturnal  emission  as  the  immediate 
exciting  cause.  In  the  author's  opinion  the  foregoing  constitutes  a  logical 
explanation  of  its  occurrence. 

In  quite  a  proportion  of  cases  prostatic  infection  in  the  course  of  gon- 
orrhea or  urethritis  results  from  deep  injections  or  the  passage  of  instru- 
ments. While  it  is  true  that  in  some  instances  the  exciting  cause  would 
seem  to  be  a  high  degree  of  chemic  irritation  produced  by  the  injection,  it 
is  probable  that  in  most  instances  in  which  the  prostatitis  can  fairly  be  at- 
tributed to  injections  the  fluid  used  is  only  indirectly  responsible  for  the 


648  DISEASES    OF    THE    PEOSTATE. 

prostatitis,  inasmiicli  as  it  serves  merel}^  as  a  carrier  of  germ-infection.  It 
is  probable  that  the  injection  of  pure  water  would  be  even  more  effective 
in  this  respect.  It  has  been  the  experience  of  the  author  that  the  frequency 
of  prostatic  complications  is  directly  proportionate  to  the  vigor  with  which 
acute  gonorrhea  is  treated.  Some  of  the  worst  cases  are  due  to  the  passage 
of  instruments  for  the  relief  of  retention  or  treatment  of  the  urethritis. 
Soluble  bougies  and  deep  urethral  irrigation,  used  during  the  acute  stages 
of  urethral  inflammation,  have  been  responsible  for  many  cases.  The  solu- 
ble bougie  or  the  tube  used  in  deep  irrigation  acts  as  a  carrier  of  germs 
which  the  injected  solution  is  too  weak  to  destroy.  Then,  too,  we  have  the 
abrading  effect  of  the  instrument  or  soluble  bougie  upon  already  degen- 
erated and  readily  removable  epithelium.  This  opens  up  avenues  of  infec- 
tion that  otherwise  might  possibly  never  develop. 

The  excessive  use  of  terebinthinate  and  balsamic  preparations  has  been 
said  to  cause  prostatitis.  It  is  possible  that  in  immense  toxic  doses  these 
(Jrugs  in  combination  with  an  already  existing  infection  of  the  deep  urethra 
may  be  operative  in  the  production  of  acute  inflammation,  but  under  no 
other  circumstances.  Cantharides  in  poisonous  doses  produces  inflamma- 
tion of  the  prostate  in  common  with  all  the  other  structures  composing  the 
genito-urinary  tract. 

In  concluding  the  etiology  of  acute  prostatitis  the  author  desires  again 
to  impress  the  paramount  importance  of  infection  as  a  factor,  and  to  again 
insist  on  the  subordinate  character  of  by  far  the  larger  proportion  of  the 
causes  enumerated,  the  simple  etiologic  classification  herein  suggested.  A 
further  practical  point  of  great  importance  is  the  clinical  fact  that,  given  an 
acute  or  chronic  source  of  infection,  and  especially  the  former,  very  slight 
interference  with  the  urethra  and  bladder  may  cause  acute  inflammation  and 
perhaps  abscess  of  the  prostate. 

Vaeieties  of  Acute  Peostatitis. — Acute  prostatitis  presents  itself 
in  several  forms,  according  to  the  method  of  causation  and  the  structures 
in  which  the  inflammation  is  mainly  localized.  "With  no  disposition  to 
dogmatism  in  classification,  the  author  inclines  to  the  view  that  the  follow- 
ing forms  of  acute  prostatitis  are  capable  of  a  clinical  differentiation  that  is 
of  vital  importance  in  their  study  and  management. 

1.  Follicular — i.e.,  parenchymatous — prostatitis,  having  its  point  of 
departure  in  posterior  urethritis  due  either  to  extension  or' transference  of 
infection  to  the  deep  urethra. 

2.  Diffuse  prostatitis,  usually  resulting  from  extension  of  the  acute 
follicular  form.  It  may  occur  as  a  primary  condition.  The  presence  and 
degree  of  interstitial  inflammation  in  the  diffuse  form  depends  upon  the 
method  of  causation:  i.e.,  whether  it  is  due  to  traumatism,  extension,  or 
lymphatic  infection.  Diffuse  prostatitis  may  be  associated  with  localized  or 
disseminated  pyogenic  infection. 

3.  Prostatitis   with   circumscribed   suppuration, — i.e.,   acute    suppura- 


VARIETIES    OF    ACUTE    PKOSTATITIS.  649 

tive  prostatitis, — due  to  extension  of  nrethral  inflammation,  infection  from 
local  absorption,  or  infection  via  the  blood. 

4.  Prostatitis  with  disseminated  foci  of  snppnration, — i.e.,  miliary 
abscesses. 

In  all  forms  of  suppurative  prostatitis  more  or  less  diffuse  interstitial 
inflammation  is  invariably  present. 

5.  Paraprostatitis.  This  is  usually,  but  not  necessarily,  followed  by 
abscess  and  is  associated  with  one  or  the  other  of  the  foregoing  forms. 

The  basis  for  classification  1  is  due  to  the  author's  belief  that  the  most 
important  ultimate  anatomic  element  of  the  prostate  is  the  secreting  gland- 
ular tissue.  According  to  this  view,  the  glands,  ducts,  and  follicles  of  the 
organ  constitute  the  true  parenchyma.  The  acute  follicular  or  parenchy- 
matous form  of  the  disease  embraces  most  of  the  cases  of  so-called  acute 
posterior  urethritis,  and  varies  in  severity  from  an  involvement  of  the  fol- 
licles alone  to  that  of  all  the  secreting  structure  of  the  organ.  The  acute  in- 
flammation of  the  prostatic  urethra  in  these  cases  is  relatively  unimportant 
in  the  pathologic  ensemhh,  save  as  the  point  of  departure  of  the  prostatic  in- 
flammation. Most  of  these  cases  should  be  classified  as  acute  follicular  or 
parenchymatous  prostatitis.  In  practically  all  cases  of  so-called  acute  poste- 
rior urethritis  from  gonorrhea  or  other  source  of  mixed  infection  the  in- 
flammation of  the  mucous  membrane  of  the  deep  urethra  is  but  a  minor 
part  of  the  morbid  condition  resulting  from  such  infection.  The  author 
cannot  conceive  of  an  acute  inflammation  of  infectious  origin  limiting  itself 
to, the  mucous  membrane  of  the  posterior  urethra.  A  few  subacute  and 
chronic  cases  may  possibly  be  met  with  in  which  the  bulbo-membranous 
region  is  involved  without  extension  or  transference  to  the  prostatic  ure- 
thra. It  is  the  author's  belief,  however,  that  in  all  cases,  acute  or  chronic, 
in  which  the  prostatic  urethra  is  involved,  the  glandular  elements  of  the 
prostate  become  affected  sooner  or  later.  In  acute  inflammation  extending 
beyond  the  bulbo-membranous  Junction  it  does  not  seem  possible  that  the 
glandular  elements  of  the  prostate  can  escape  involvement.  It  is  certainly 
open  to  argument  whether  the  consideration  of  so-called  posterior  urethri- 
tis as  acute  or  chronic  follicular  inflammation  of  the  prostate  rather  than  a 
disease  of  the  urethra  per  se  might  not  be  of  great  practical  clinical  impor- 
tance as  explaining  the  extreme  obstinacy  of  the  disease  and  the  impossi- 
bility of  curing  it  completely  by  applications  to  the  relatively  small  and 
unimportant  infected  area  presented  by  the  mucous  membrane  lining  the 
prostatic  urethra.  Looking  at  posterior  urethritis  from  this  stand-point, 
the  question  might  arise  whether  deep  injections  of  astringents  may 
not  defeat  the  very  object  that  the  practitioner  strives  to  attain  in  such 
cases,  by  impeding  drainage  from  the  glandular  elements  and  ducts  of 
the  prostate  constituting  the  principal  seat  of  the  infectious  inflamma- 
mation.  Associated  with  these  cases  there  is  usually  more  or  less  involve- 
ment of  the  interstitial  tissue  surrounding  the  ducts  and  glands,  the  re- 


650  DISEASES    OF   THE    PEOSTATE, 

suiting  mechanic  conditions  depending  entirely  upon  the  degree  of  involve- 
ment. 

From  a  clinical  stand-pointy,  there  would  seem  to  be  a  broad  line  of  dis- 
tinction between  the  acute  cases  of  follicular  inflammation  from  extension 
of  infection  from  the  prostatic  urethra  and  those  that  result  from  lymphatic 
absorption  or  infection  of  an  abraded  surface  produced  by  traumatism,  and 
leading  to  prostatic  or  periprostatic  abscess.  On  the  one  hand,  we  have  pri- 
marily all  of  those  symptoms  characteristic  of  irritation  and  inflammation 
of  the  true  vesical  neck, — i.e.,  the  prostatic  urethra;  while,  on  the  other 
hand,  we  have  much  less  vesical  irritability  with  the  development  of  more 
or  less  sudden  obstruction  to  the  outflow  of  urine.  In  acute  follicular  in- 
flammation retention  of  urine  is  rare;  not  so  in  cases  in  which  severe  inter- 
stitial inflammation  develops.  So  frequent,  however,  is  the  association  of 
retention  with  prostatic  abscess  that  the  latter  is  to  be  strongly  suspected 
in  all  cases  of  acute  prostatitis  in  which  retention  is  a  prominent  factor.^ 

In  diffuse  prostatitis  there  is  usually,  as  a  result  of  extension  of  infec- 
tion from  the  prostatic  urethra,  very  severe  glandular  inflammation.  As- 
sociated with  this  is  pronounced  involvement  of  the  interstitial  tissue.  In 
these  cases,  on  account  of  the  anatomic  conditions  already  outlined,  pain 
and  constitutional  symptoms  are  more  marked  than  in  the  acute  follicular 
form.  Diffuse  prostatitis  may  be  the  result  of  lymphatic  absorption,  in 
which  event  pain,  rectal  tenesmus,  and  urinary  obstruction  may  develop 
without  preliminary  vesical  irritability.  Abscesses  may  or  may  not  occur 
in  the  diffuse  variety  of  acute  prostatitis.  When  they  do  occur  they  may 
be  the  result  of  a  general  infection  of  the  organ,  or  an  occluded  duct  or 
follicle  may  constitute  the  primary  focus  of  infection,  subsequently  ruptur- 
ing and  infecting  the  surrounding  prostatic  tissues. 

Acute  Suppueative  Peostatitis. — According  to  the  classification 
already  given,  acute  suppurative  inflammation  of  the  prostate  may  occur  in 
any  one  of  three  forms,  viz.:  1.  Circumscribed  abscess,  single  or  multiple. 
These  abscesses  may  involve  any  particular  portion  of  the  prostate;  they 
may  be  of  considerable  size,  and  one  or  more  may  coalesce,  forming  a  large 
abscess.  2.  Disseminated  suppuration:  i.e.,  miliary  abscesses.  3.  Peripro- 
static abscess,  with  or  without  suppuration  in  the  prostate  proper. 

Etiology. — While  usually  due  to  local  sources  of  infection,  any  of 
these  forms  of  abscess  may  result  from  general  pyogenic  infection  and 
may  be  caused  by  such  infectious  diseases  as  variola  and  mumps.  Some 
abscesses  are  primarily  due  to  extension  of  suppurative  inflammation, 
while  others  are  due  to  lymphatic  absorption  and  infection  of  the  pro- 
static tissues.  In  some  instances,  in  all  probability,  one  or  more  of  the 
numerous  ducts   of  the   prostate  become   occluded  by  the  inflammatory 


^  Due   consideration  should,  however,  be  given  to  the  possibility  of  spasmodic 
retention  in  deep-seated  inflammation. 


ACUTE    SUPPURATIVE    PROSTATITIS.  651 

swelling  incidental  to  virulent  inflammation,  with  consequent  retention  of 
infectious  pus  in  the  form  of  a  small  abscess-cavity  the  walls  of  which  are 
composed  of  the  walls  of  the  duct  or  follicle  involved.  Such  circumscribed 
retention-abscesses  constitute  foci  of  infection  of  the  surrounding  tissues. 
Forming  at  the  periphery  of  the  organ,  they  may  rupture  into  the  para- 
prostatic  tissue,  with  resulting  abscess  outside  the  prostate  proper. 

Disseminated  foci  of  suppuration  in  the  prostate  constitute  the  variety 
that  is  most  likely  to  occur  from  constitutional  infection.  The  rupture  of 
such  a  focus,  however  small,  into  the  periprostatic  tissue  will  almost  inevi- 
tably result  in  abscess  in  this  situation. 

It  is  unnecessary  to  expatiate  at  length  upon  paraprostatitis;  the  most 
important  points  have  already  been  dilated  upon.  It  generally  occurs  as  a 
secondary  factor  in  some  one  of  the  foregoing  forms  of  acute  inflammation. 
Suppuration  usually  occurs,  and  in  some  cases  the  amount  of  pus  may  be 
rather  startling,  the  pus  burrowing  extensively  about  the  rectum.  Eeten- 
tion  of  urine  is  usual  in  marked  cases. 

The  subject  of  acute  prostatic  abscess  is  intimately  blended  with  that 
of  acute  prostatitis;  there  are  several  points,  however,  in  connection  with 
prostatic  suppuration  that  merit  special  attention! 

Abscess  of  the  prostate  in  connection  with  hypertrophy  of  the  organ 
is  more  frequent  than  ordinarily  supposed.  It  may  occur  spontaneously 
from  infection,  although  this  is  extremely  rare.  Most  often  it  is  the  direct 
result  of  traumatism  inflicted  during  the  treatment  of  the  disease,  or  dur- 
ing catheterization  for  the  relief  of  retention  produced  by  it.  The  author 
is  of  opinion  that,  in  quite  a  proportion  of  cases  of  death  following  reten- 
tion of  urine  dependent  upon  hypertrophied  prostate  necessitating  pro- 
longed and  frequent  instrumentation  for  its  relief,  the  immediate  cause  is 
general  septic  or  pus  infection  from  suppuration  of  the  prostate  induced 
by  the  surgical  interference.  Several  cases  have  come  under  the  author's 
observation  in  which  the  patient  developed  constitutional  manifestations 
of  sepsis,  and  finally  sank  into  a  typhoid  condition  and  died,  as  a  conse- 
quence of  extensive  prostatic  and  periprostatic  abscess  that  was  directly 
traceable  to  bunglesome  and  injudicious  catheterization.  In  some  of  these 
eases  the  abscess  is  subacute  or  chronic  and  of  prolonged  duration.  Rupture 
may  finally  occur  into  the  urethra,  rarely  externally,  in  which  event  there 
may  be  sudden  relief  of  obstruction.  It  is  noteworthy,  that  some  cases  of 
prostatic  abscess  occurring  in  enlarged  prostate  are  ultimately  followed  by 
great  benefit  to  the  primary  condition.  The  destruction  of  prostatic  tissue 
by  the  abscess  is  followed  by  cicatricial  contraction  and  diminution  of  the 
mechanic  obstruction  produced  by  the  enlargement.  In  some  instances, 
however,  the  abscess-cavity  does  not  become  obliterated,  but  remains  as  a 
suppurating  pocket,  opening  more  or  less  freely  into  the  lumen  of  the  ure- 
thra and  giving  rise  to  successive  reinfections  of  the  posterior  urethra  and 
bladder  or  even  infection  of  the  anterior  portion  of  the  canal.    This  is  true 


652  DISEASES    OF    THE    PEOSTATE. 

of  all  forms  of  prostatic  abscess.  In  abscess  occurring  in  prostatic  hyper- 
trophy it  is  interesting  to  note  the  marked  diminution  in  the  size  of  the 
portion  of  the  prostate  that  happens  to  be  the  seat  of  suppuration.  In  a 
case  recently  seen  an  abscess  in  the  right  lobe  of  the  prostate  in  a  middle- 
aged  man  with'  prostatic  hypertrophy  had  produced  so  much  shrinkage  of 
the  organ  that  it  was  hardly,  if  at  all,  larger  than  the  normal,  while  the 
oi)posite  side  was  still  markedly  hypertrophied  and  indurated. 

The  occasional  occurrence  of  prostatic  abscess  in  prostatiques  consti- 
tutes a  very  practical  point  in  the  study  of  prostatic  hypertrophy.  It  is 
by  no  means  unusual  for  the  first  severe  symptoms  of  prostatic  obstruction 
in  old  men  to  occur  coincidently  with  the  formation  of  prostatic  abscess. 
Inasmuch  as  after  evacuation  of  the  pus  the  symptoms  practically  disap- 
pear, an  erroneous  diagnosis  may  be  made,  the  case  being  considered  as 
ab  initio  one  of  prostatic  suppuration. 

That  a  fatal  result  may  follow  prostatic  abscess  not  only  in  old,  but  in 
young,  subjects  must  be  borne  in  mind.  A  case  recently  came  under  the 
author's  observation  of  a  young  man,  35  years  of  age,  who  died  of  what 
was  diagnosed  as  typhoid  fever,  but  which,  as  the  autopsy  showed,  was  sep- 
sis due  to  a  large  prostatic  abscess.  It  is  well  in  all  cases  of  serious  pro- 
static disease  to  keep  a  close  watch  for  both  local  and  constitutional  symp- 
toms of  suppuration.  Free  incision  and  drainage  would  probably  have 
saved  the  life  of  the  patient  to  whom  allusion  has  been  made.  In  all  cases 
of  acute  prostatic  inflammation,  especially,  it  is  the  duty  of  the  surgeon  to 
be  on  the  alert  for  symptoms  of  suppuration.  Oftentimes,  however,  a  diag- 
nosis can  only  be  made  after  the  pus  has  discharged  into  the  urethra,  blad- 
der, or  rectum.  Healing  of  prostatic  abscess  after  such  evacuation  is  often 
quite  prompt,  but  in  many  cases  the  admixture  of  urine  with  the  contents 
of  the  abscess  causes  serious  trouble  by  subsequent  decomposition  and  sep- 
tic absorption. 

Ano-rectal  fistula  may  result  in  cases  in  which  the  abscess  opens  or  is 
evacuated  by  the  knife  via  the  rectum.  Urinary  fistula  communicating 
with  the  rectum  or  with  the  ano-rectal  fistula  may  also  develop.^  Urinary 
fistula  following  evacuation  of  the  pus  via  the  perineum  is  not  infrequent. 

MoEBiD  Ain'atomy  OF  AcuTE  Peostatitis,  Simple  axd  Suppueative. 
— Comparatively  little  is  known  of  the  early  stages  of  acute  prostatic  inflam- 
mation, especially  of.  the  follicular  or  parenchymatous  form.  The  condition 
is  not  fatal,  and  opportunities  for  observation  are  consequently  not  numer- 
ous. So  far  as  determined,  however,  the  process  appears  to  be  at  first  lim- 
ited chiefly  to  the  mucous  membrane  and  the  follicles  and  glands  imme- 
diately tributary  to  the  prostatic  urethra;  hence  a  description  of  the  morbid 


^  The  author  has  imder  his  care  a  gentleman  in  ■whom  a  long-standing  fistula 
exists  bet-sveen  the  rectum  and  prostatic  urethra  from  this  cause. 


MOEBID   ANATOMY    OF   ACUTE    PROSTATITIS.  653 

anatomy  of  acute  follicular  prostatitis  in  its  incipiency  is  also  that  of  acute 
posterior  urethritis.  In  the  follicular  form  there  is  always  a  varying  degree 
of  involvement  of  the  interstitial  tissue,  largely  dependent  upon  the  dura- 
tion of  the  disease.  The  infectious  inflammation  probably  never  limits  itself 
to  the  prostatic  urethra;  if  the  inflammation  does  not  extend  below  the 
membranous  urethra,  however,  it  may  possibly  become  limited  if  not  acute. 
In  acute  bulbo-membranous  inflammation  the  prostatic  u.rethra  is  almost 
inevitably  involved  sooner  or  later.  The  mucous  membrane  of  the  prostate 
is  reddened  and  thickened,  as  is  true  of  all  inflamed  mucous  membranes. 
There  is  almost  invariably  thickening  of  the  tissues  surrounding  the  lym- 
phatics and  blood-vessels. 

Ulceration  does  not  occur,  and  resulting  stricture  is  so  exceedingly 
rare  that  it  is  hardly  worth  consideration.  The  mouths  of  the  prostatic  and 
ejaculatory  ducts  are  involved  in  the  inflammation,  thus  serving  to  explain 
the  facility  with  which  it  extends  to  the  glandular  tissues  of  the  organ.  In 
acute  parenchymatous  or  follicular  prostatitis  the  organ  is  swelled  accord- 
ing to  the  degree  of  circulatory  disturbance  and  periglandular  swelling.  If 
the  process  extends  to  the  interglandular,  muscular,  and  periprostatic  tis- 
sues, the  diifuse  form  of  inflammation,  as  interpreted  by  the  author,  is  de- 
veloped. This  corresponds  to  the  parenchymatous  form  as  described  by 
Thompson.  The  organ  is  swelled  in  some  cases  to  three  or  four  times  its 
natural  size.  The  veins  of  the  prostatic  plexus  are  distended  by  dark  blood. 
The  arterial  vascular  supply  is  also  engorged.  The  mucous  membrane  of  the 
prostate  is  of  a  darker-red  hue  than  usual.  Pressure  causes  exudation  of  a 
cloudy,  reddish  fluid  containing  blood  from  the  engorged  capillaries  and 
venules,  inflammatory  lymph,  and  fluid  from  the  prostatic  glands,  with  a 
small  quantity  of  pus.  Brissaud  and  Segond  give  a  very  clear  description 
of  the  pathologic  anatomy  of  acute  diffuse  prostatitis,  as  observed  in  a  man 
dead  of  complicating  pleuro-pneumonia.  The  glandular  tubes  were  the  seat 
of  inflammation  varying  in  intensity  at  different  points.  The  internal  wall 
of  the  ducts  at  points  where  the  inflammation  was  most  intense  appeared  to 
be  blended  with  the  muscular  tissue  by  inflammatory  exudate.  The  inequal- 
ity of  the  inflammatory  process  was  especially  noticeable.  In  different  places, 
notably  at  the  periphery  of  the  organ,  marked  pathologic  changes  in  some 
of  the  glandular  tissues  co-existed  with  a  healthy  condition  of  neighboring 
glands  and  ducts.  The  epithelium  lining  the  glandular  cul-de-sacs  and 
ducts  was  replaced  by  an  agglomeration  of  new  tissue-elements,  often  filling 
the  ampullse  of  the  glands  completely.  In  some  instances  the  degenerative 
changes  had  obliterated  the  normal  glandular  outlines. 

Prostatic  suppuration  presents  itself  in  several  forms.  In  the  follicular 
form  it  is  similar  to  that  in  gonorrhea  or  urethritis:  the  pathologic  condi- 
tion from  which  the  process  in  the  prostate  was  originally  derived.  Cir- 
cumscribed abscess  may  form  in  follicular  prostatitis.  One  or  more  glands 
become  infected,  and  incidentally  their  ducts  are  involved.     Occlusion  of 


654  DISEASES    OF    THE    PKOSTATE. 

the  latter  may  occur  and  a  suppurating-cyst-like  accumulation  of  pus  re- 
sult. One  or  more  of  these  accumulations  may  rupture  and  contaminate 
the  remainder  of  the  gland.  Such  abscesses  are  often  responsible  for  re- 
current infection.  Miliary  abscesses  may  result  from  acute  suppuration. 
They  may  be  single  or  multiple,  and  more  or  less  disseminated.  Large 
abscesses  may  be  found  in  some  cases.  Abscess  may  occur  in  the  cellular 
tissue  surrounding  the  prostate:  periprostatic  abscess.  Some  prostatic  ab- 
scesses are  very  large.  Guyon  reports  a  case  in  which  the  urethra  was  com- 
pletely dissected  out  of  the  prostate,  and  the  urethra  completely  surrounded 
by  pus.  Abscess-cavities  are  generally  multilocular  and  trabeculated.  These 
abscesses  may  open  into  the  urethra  by  one  or  numerous  openings. 

Lallemand  many  years  ago  called  attention  to  the  fact  that  in  acute 
prostatitis  the  ejaculatory  ducts  may  be  dilated  and  thickened  from  in- 
volvement of  the  mucous  membrane.  They  may  be  ulcerated  or  their  lumen 
diminished  or  even  occluded.  The  seminal  vesicles  are  usually  thickened, 
dilated,  and  contain  reddish  or  puro-sanguinolent  fluid.  Eegarding  the 
accuracy  of  Lallemand's  observations  a  certain  element  of  doubt  is  war- 
rantable; many  of  his  patients  were  subjected  to  treatment  by  the  yorte- 
caustique,  which  in  itself  was  not  only  likely  to  set  up  acute  prostatitis,  but 
followed  by  occlusion  of  the  ejaculatory  ducts. 

In  some  cases  of  suppuration  the  entire  glandulo-muscular  structure 
of  the  prostate  is  destroyed,  as  in  the  case  outlined  by  Guyon.  Such  a  case 
has  come  under  the  author's  observation.  It  is  a  matter  of  regret  that  the 
autopsy  in  this  case  was  not  made  with  more  care,  the  specimen  being  by 
no  means  perfect.  The  prostate,  however,  was  practically  replaced  by  a 
suppurating  cavity  with  quite  thick  walls,  apparently  representing  the  cap- 
sule of  the  prostate  in  conjunction  with  inflammatory  new  growth.  The 
specimen  was  so  damaged  in  removal  that  it  was  impossible  to  obtain  a 
clear  idea  of  the  relation  of  the  urethra  to  the  abscess. 

Symptoms. — In  acute  follicular  prostatitis  the  symptoms  are  mainly 
subjective.  Frequent  and  painful  urination,  pain  being  especially  marked 
at  the  termination  of  the  act,  and  in  some  cases  a  certain  amount  of  blood 
mixed  with  the  last  few  drops  of  urine  constitute  the  principal  local  symp- 
toms. A  feeling  of  perineal  distress  with  pain  radiating  along  the  urethra 
into  the  spermatic  cords  or  down  the  inner  aspect  of  the  thighs  is  frequently 
experienced.  In  some  cases  there  is  more  or  less  rectal  pain  and  tenesmus. 
The  stools  are  likely  to  be  somewhat  painful.  There  may  be  considerable 
constitutional  disturbance,  but,  as  a  rule,  this  is  very  slight,  excepting  where 
there  is  more  or  less  diffuse  inflammation.  In  the  diffuse  and  suppurative 
varieties  there  is  more  or  less  urinary  obstruction.  Complete  retention  may 
come  on  and  persist  until  the  abscess  is  evacuated,  when  speedy  relief  is 
experienced.  When  pyogenic  infection  occurs  independently  of  follicular 
inflammation,  there  may  be  comparatively  little  vesical  irritation,  the  sjonp- 
toms  of  urinary  obstruction  preponderating.     This  is  especially  apt  to  be 


SYMPTOMS    OF   ACUTE    PEOSTATITIS.  655 

the  case  in  acute  abscesses  that  develop  in  the  course  of  prostatic  hyper- 
trophy. 

In  diffuse  and  suppurative  prostatitis,  pain  and  constitutional  symp- 
toms are  especially  marked.  Depression  is  likely  to  be  profound,  and  in 
prostatiques  especially  the  patient  may  sink  into  a  typhoid  state  and  die 
with  all  the  symptoms  of  constitutional  pyogenic  infection.  True  pyemia 
may  result  as  a  consequence  of  localized  suppuration.  The  formation  of 
pus  is  likely  to  be  heralded  by  a  distinct  chill,  followed,  in  some  cases,  by 
a  succession  of  chills. 

In  some  cases  of  acute  prostatitis  the  disease  develops  very  suddenly; 
in  others  a  few  hours,  or  possibly  several  days,  may  elapse  before  the  symp- 
toms become  prominent.  During  this  period  the  patient  experiences  pre- 
monitory sensations  of  weight  and  fullness  in  the  perineum,  with  frequent 
micturition  and  a  certain  degree  of  depression  incidental  to  irritation  of  the 
vesical  neck.  If  abscess  forms  severe  throbbing  pain  is  likely  to  come  on. 
This  may  be  lancinating  rather  than  throbbing,  radiating,  as  already  stated, 
into  the  urethra,  groins,  and  thighs.  The  slightest  exercise  tends  to  ag- 
gravate the  symptoms.  The  patient  very  often  finds  quite  early  in  the  course 
of  the  disease  that  slight  perineal  pressure  elicits  considerable  pain  and 
tenderness,  and  possibly  vesical  irritability. 

Cystitis  may  co-exist  with  acute  prostatitis,  but  in  the  opinion  of  the 
author  this  is  infrequent,  all  of  the  symptoms  being  usually  explicable  by  in- 
flammation of  the  prostatic  urethra.  In  cases  having  their  point  of  departure 
in  follicular  inflammation,  the  urine  contains  muco-pus  from  two  sources: 
1.  That  which  is  directly  washed  out  of  the  prostatic  urethra  by  the  out- 
flowing urine.  2.  That  which  has  taken  the  directio»  of  least  resistance 
backward  into  the  bladder  during  the  intervals  of  micturition.  The  first 
and  last  portions  of  the  urine  in  follicular  prostatitis  are  likely  to  contain 
considerable  muco-pus,  the  midstream  being  comparatively  clear.  When 
there  is  no  follicular  inflammation,  the  condition  being  primarily  diffuse 
inflammation  or  localized  inflammation  incidental  to  infection  and  followed 
by  suppuration,  the  urine  contains  nothing  characteristic  until  the  abscess 
ruptures  into  the  urethra  or  bladder.  The  patient  then  experiences  sudden 
relief  in  the  perineum  and  ano-rectal  region,  the  urine  flows  with  perhaps 
its  usual  freedom,  or  at  least  much  more  easily  than  before  the  rupture  of 
the  abscess,  and  pus  suddenly  appears  in  the  urine.  It  does  not  usually 
escape  from  the  urethra  during  the  intervals  of  micturition  unless  secondary 
infection  of  the  anterior  urethral  mucous  membrane  occurs,  or  the  point  of 
rupture  is  located  anterior  to  the  bulbo-membranous  junction. 

The  objective  symptoms  of  acute  prostatitis  vary  with  the  degree  of 
diffuse  inflammation.  Where  the  pathologic  process  is  largely  follicular, 
as  in  a  certain  proportion  of  cases  of  so-called  posterior  urethritis,  local  ex- 
amination elicits  very  little  save  more  or  less  tenderness  on  deep  perineal 
pressure  and  manipulation  of  the  membranous  and  prostatic  portions  of 


656  DISEASES    OF    THE    PROSTATE. 

the  urethra  per  rectum.  Deep  pressure  behind  the  pubes  may  elicit  some 
tenderness  referable  to  the  vesical  neck.  In  the  more  severe  types  of  dif- 
fuse and  circumscribed  suppurative  inflammation^  more  or  less  heat,  swell- 
ing, tension,  and  tenderness  of  the  perineum  are  noticeable.  The  prostate 
jDresents  itself  as  a  hot,  tender  tumor  projecting  into  the  rectum  antero- 
posteriorly.  The  degree  of  enlargement  varies  with  the  extent  of  inter- 
stitial inflammation  and  may  be  so  marked  that  the  finger  cannot  be  intro- 
duced into  the  rectum  without  considerable  difficulty  and  the  infliction  of 
severe  pain.  When  suppuration  has  occurred  a  boggy,  edematous,  uniform, 
or  circumscribed  bulging  of  the  prostate  and  periprostatic  tissues  into  the 
rectum  is  noticeable.    Later  on,  fluctuation  may  be  evident. 

Diagnosis. — Although  the  main  diagnostic  points  in  acute  prostatitis 
have  been  outlined  in  the  foregoing  symptomatology,  a  resume  and  con- 
sideration of  certain  special  points  in  the  differential  diagnosis  are  requisite. 
The  patient,  generally  the  subject  of  acute  or  chronic  urethritis  or  chronic 
prostatic  disease,  complains  for  several  days  of  heaviness  and  pain  in  the 
perineum,  which  he  is  quite  likely  to  attribute  to  fatigue  or  overexertion,  or 
possibly,  if  he  be  exceptionally  honest,  to  sexual  stimulation  or  indulgence. 
In  some  cases  he  complains  for  several  days  of  loss  of  appetite,  possibly  slight 
chilliness,  and  well-marked  malaise.  Considerable  mental  depression  may 
exist  for  several  days  before  definite  symptoms  referable  to  the  perineum 
develop.  Vesical  and  anal  tenesmus  with  dysuria,  and  in  the  majority  of 
cases  painful  and  difficult  defecation,  soon  come  on.  In  other  instances 
the  first  indications  of  impending  prostatic  inflammation  is  vesical  irrita- 
tion. In  still  another  class  of  cases  the  first  and  most  prominent  sj^mptom 
consists,  not  in  vesical  irritabilit}^,  but  in  urinary  obstruction  that  grows 
more  and  more  prominent  and  may  lead  to  complete  retention.  It  is  ob- 
vious that  the  symptoms  are  governed  largely  by  the  amount  of  inflam- 
mation of  the  prostatic  urethra. 

Where  inflammation  of  the  posterior  urethra  is  not  the  point  of  de- 
parture, as  is  true  of  many  suppurative  cases,  there  may  be  little  or  no  vesical 
irritation  throughout  the  course  of  the  case.  Digital  exploration  of  the  rec- 
tum and  perineum  shows  perineal  fullness  and  tenderness  and  a  degree  of 
bulging  of  the  prostate  into  the  rectum,  due  to  enlargement  of  the  organ, 
proportionate  to  the  severity  of  the  inflammation  and  the  degree  to  which 
the  interstitial  and  periprostatic  tissues  are  involved. 

Cowperitis  may  be  mistaken  for  inflammation  of  the  prostate.  Palpa- 
tion of  the  perineum,  however,  shows  lateral  swelling  and,  if  examined 
early,  a  distinctly  circumscribed  spheric  tumor.  The  prostate,  on  rectal 
examination,  is  found  to  be  either  normal  or  only  moderately  enlarged. 
The  urinary  symptoms  may  be  nil.  The  possibility  of  follicular  prosta- 
titis, without  much  enlargement  of  the  prostate,  existing  as  a  complication 
of  cowperitis,  or  vice  versa,  should  be  taken  into  consideration. 

Acute  prostatitis  complicated  by  retention  may  require  differentiation 


PEOGNOSIS    OF    ACUTE    PEOSTATITIS.  657 

from  stricture,  especially  that  variety  in  which  retention  comes  on  sud- 
denly from  hyperemia  and  spasm.  The  history  of  the  case,  digital  explora- 
tion of  the  rectum,  and  the  location  of  the  obstruction  generally  serve  for 
differentiation.  It  mast  be  remembered,  however,  that  stricture  of  the 
urethra  is  quite  likely  to  be  complicated  by  prostatic  inflammation.  Many 
cases  of  acute  genito-urinary  disease  are  likely  to  present  features  that 
are,  to  say  the  least,  decidedly  mixed.  Enlargement  of  the  prostate,  as  a 
cause  of  retention,  may  usually  be  differentiated  from  acute  prostatitis  by 
the  age  and  history  of  the  patient,  and  the  peculiar  feel  imparted  to  the 
finger  in  rectal  exploration.  The  tenderness  elicited  by  the  latter  method 
may  be  very  slight  in  prostatic  hypertrophy.  The  possibility  of  acute  pros- 
tatitis with  suppuration  or  the  formation  of  chronic  abscess  as  a  complica- 
tion of  prostatic  hypertrophy  is  to  be  borne  in  mind. 

Acute  cystitis  may  be  mistaken  for  inflammation  of  the  prostate.  It 
is  probable  that  a  majority  of  cases  of  so-called  acute  gonorrheal  cystitis 
are  really  instances  of  acute  follicular  prostatitis.  The  vesical  mucosa  proper 
is  rarely  involved  in  gonorrheal  inflammation;  indeed,  it  has  been  claimed 
that  the  vesical  mucosa  is  immune  to  the  gonococcus.  Be  this  as  it  may, 
gonorrhea  is  a  mixed  infection  and  the  vesical  mucosa  may  become  infected 
by  germs  other  than  the  gonococcus.  It  is  not,  however,  particularly  sus- 
ceptible to  simple  pus-infection. 

When  abscess  of  the  prostate  is  definitely  formed,  the  diagnosis  is  gen- 
erally easy  if  the  collection  of  pus  is  not  quite  small;  it  is  especially  easy 
when  the  abscess  points  toward  the  rectum.  In  some  cases,  however,  the 
diagnosis  is  not  only  difficult,  but  the  abscess  is  not  detected  until  the  pus 
has  escaped  by  the  urethra.  The  author  has  observed  a  number  of  cases  in 
which,  although  prostatic  abscess  was  strongly  suspected,  the  symptoms  were 
of  moderate  intensity;  no  incision  was  made  and  the  diagnosis  was  only 
cleared  up  by  the  sudden  escape  of  a  greater  or  less  quantity  of  pus  from 
the  urethra. 

Zeissl  calls  attention  to  the  possibility  of  confusion  of  prostatic  with 
ischio-rectal  abscess.  In  the  latter,  however,  there  are  no  special  symp- 
toms referable  to  the  bladder,  as  a  rule,  and  the  unilateral  position  of  the 
tumor,  with  its  distinct  point  of  departure  in  the  ischio-rectal  fossa,  serves 
to  clear  up  the  diagnosis.  In  some  rarer  instances  ischio-rectal  abscess  is 
associated  with  more  or  less  reflex  vesical  irritation.  This  may  prove  a 
source  of  confusion.  The  author  has  observed  one  case  in  which  ischio- 
rectal abscess  occurred  coincidently  with  acute  follicular  prostatitis.  The 
possibility  of  the  co-existence  of  the  two  conditions  is  to  be  borne  in  mind. 
In  prostatic  phlegmon,  and  in  all  forms  of  well-marked  prostatic  inflam- 
mation, especially  where  suppuration  occurs,  the  gravity  of  the  constitu- 
tional symptoms  and  the  profound  nervous  depression  are  valuable  points 
in  the  differential  diagnosis. 

Peognosis. — The  prognosis  of  acute  prostatitis  in  otherwise-healthy 


658  DISEASES    OE    THE    PEOSTATE. 

subjects  is  quite  faTorable  as  regards  immediate  recoTery  of  tlie  patient, 
Arlietlier  suppuration  oc-euis  or  not.  As  already  indicated,  some  cases  of 
suppuration  prove  fatal,  this  being  especially  true  of  tbe  phlegmonous  form 
that  occurs  sometimes  in  young  subjects,  but  more  often  in  prostatiques, 
in  whom  general  debility  is  more  marked,  on  the  average,  than  in  younger 
men.  The  local  symptoms  are  likely  to  be  improved  in  this  class  of  cases 
after  the  STacuation  of  the  abscess. 

According  to  Segond,  the  prognosis  of  generalized  prostatic  phlegmon 
is  grave.  In  114  cases  collected  by  this  authority,  there  were  34  deaths, 
10  cases  in  which  permanent  fistula  followed,  and  70  recoveries.  Segond's 
statistics,  however,  are  not  a  fair  criterion  of  the  gravity  of  prostatic  ab- 
scess taken  as  a  whole.  In  many  cases,  even  of  prostatic  phlegmon,  an  in- 
correct diagnosis  is  made,  yet  the  patient  eventually  recovers  after  evacua- 
tion of  the  pus.  In  the  milder  cases  of  prostatic  abscess  pus  very  frequently 
discharges  into  the  deep  urethra  and  bladder  and  apparent  cure  results,  the 
true  condition  of  affairs  being  unrecognized.  It  is  the  opinion  of  the  author 
that  many  cases  in  which  subsidence  of  the  prostatic  symptoms  is  coinci- 
dental with  a  sudden  and  marked  recurrence  of  urethral  discharge  come 
under  this  head.  In  such  cases  the  recurrence  of  urethral  discharge  is  due, 
first,  to  the  escape  of  the  abscess-contents:  second,  to  autoinfection  of  the 
urethra  by  the  prostatic  pus. 

In  both  young  and  old  subjects  with  prostatic  abscess  persistent  p}-uria 
with  exacerbations  of  cystitis  and  urethritis  may  supervene.  The  abscess, 
after  evacuation  into  the  urinary  tract,  instead  of  closing  down  and  becom- 
ing obliterated,  remains  as  a  suppurating  sac  with  one  or  more  openings 
into  the  urinary  canal.  Decomposing  urine  and  products  of  suppurative  in- 
flammation may  perpetuate  this  condition  of  affairs  indefinitely.  In  most 
eases  in  which  abscess  forms  without  marked  follicular  inflammation,  the 
patient  recovers  completely.  In  the  follicular  form  of  the  disease,  how- 
ever, and  in  those  diffuse  and  suppurative  forms  in  which  follicular  in- 
flammation is  the  primary  condition,  the  case  is  apt  to  become  very  stub- 
bom.  It  is  probable  that  no  patient  who  has  ever  suffered  from  acute  fol- 
licular prostatitis  ever  recovers  completely.  The  proportion  of  patients  who 
have  chronic  inflammation  of  the  prostate  following  acute  follicular  pros- 
tatitis of  gonorrheal  origin  is  much  greater  than  ordinarily  believed.  Cases 
taken  at  random  and  studied  upon  the  post-mortem  table  in  our  large  cities 
will  substantiate  the  accuracy  of  this  assertion.  In  a  careful  study  of  nearly 
two  hundred  prostates,  taken  in  this  way,  the  author  found,  in  by  far  the 
larger  proportion,  evidences  of  more  or  less  recent  inflammation  in  which, 
apparently,  the  primary  condition  had  been  acute  follicular  inflammation. 
Practical  observation  tends  to  show  that  a  prostate,  the  glandular  tissue  of 
which  is  once  infected,  is  likely  to  be  always  more  or  less  diseased,  whether 
there  are  symptoms  or  not. 

Teeatmext. — The  treatment  of  acute  prostatitis  should  be  active.    A 


TREATMENT    OF    ACITTE    PE0STATITI3.  659 

brisk  mercurial  purge  should  be  given,  followed  by  a  full  dose  of  some  saline 
in  the  course  of  three  or  four  hours.  This  will  unload  the  portal  circulation 
and  produce  general  depletion.  An  excellent  plan  is  to  administer  tablet 
triturates  of  calomel,  ^/^  grain  every  three  hours  until  four  or  five  doses 
have  been  given.  Coincidently  4-ounce  enemas  of  saturated  solution  of 
sulphate  of  magnesia,  containing  glycerin  in  the  proportion  of  about  1  to 
3,  should  be  given.  This  may  be  repeated  until  a  number  of  watery  evacua- 
tions have  resulted.  This  is  the  ideal  method  of  pelvic  depletion,  and  is 
quite  as  valuable  in  prostatic  disease  as  in  pelvic  and  abdominal  inflamma- 
tion in  the  female.  Having  fulfilled  this  indication,  there  are  several  spe- 
cial measures  that  are  essential.  The  febrile  symptoms  call  for  aconite  or 
veratrum  viride,  remedies  far  more  reliable  than  antimony — recommended 
by  Thompson.  Ergot  and  hamamelis  are  probably  beneficial.  They  are 
certainly  philosophic  remedies  from  a  theoretic  stand-point.  These  reme- 
dies may  advantageously  be  combined  with  gelsemium  and  the  bromid  of 
potassium:  anaphrodisiac  remedies  ha^ang  a  special  sedative  effect  upon  the 
inflamed  organ.  Hypodermic  injections  of  pilocarpin  are  serviceable,  this 
remedy  being  a  powerful  derivative. 

After  the  bowels  have  been  thoroughly  evacuated  opium  is  the  most 
effective  remedy.  It  relieves  pain  and  strangury,  lessens  the  frequency  of 
micturition,  and  counteracts  nervous  depression.  All  anodynes  act  best  in 
acute  prostatitis  when  given  by  suppository.  If  the  rectum  be  irritable, 
the  anodyne  may  be  injected  into  the  gut  in  the  form  of  a  thin  ointment. 
Iodoform  or  europhen  may  be  combined  with  morphin  and  belladonna  or 
hyoscyamus,  and  administered  by  suppository.  Caution  is  necessary  in  using 
anodynes  per  rectum,  as  most  patients  are  very  susceptible  to  them  when  so 
given.  If  the  administration  of  anodynes  p&r  orem  be  considered  preferable 
to  rectal  medication,  codein  will  be  found  reliable  and  much  less  disagree- 
able than  other  preparations  of  opium. 

The  diet  should  be  restricted  to  milk  or  other  unstimulating  fluid 
aliment,  and  the  patient  should  lie  quietly  upon  his  back  with  the  hips 
slightly  elevated.  He  should  be  impressed  with  the  absolute  necessity  of 
perfect  rest  for  some  weeks,  for  in  no  disease  is  movement  more  likely  to 
aggravate  the  condition  than  in  prostatitis.  In  many  cases  in  which  acute 
prostatitis  assumes  a  subacute  or  chronic  form  and  persists  indefinitely, 
movement,  sexual  excitement,  and  alcoholic  and  dietetic  indulgence  are 
in  great  measure  responsible.  Too  much  stress  cannot  be  put  upon  the 
necessity  of  perseverance  in  the  rules  of  genito-urinary  hygiene. 

Local  depletion  should  be  resorted  to  early  and  repeated  from  time  to 
time  as  required.  This  is  best  accomplished  by  means  of  leeches.  Five  to 
eight  leeches  should  be  applied  to  the  perineum  and  about  the  anus,  and 
the  bleeding  encouraged  by  warm  fomentations.  The  rationale  of  this  treat- 
ment is  obvious,  if  the  intimate  association  of  the  prostatic  and  inferior 
hemorrhoidal  plexuses  be  considered.     After  hemorrhage  has  ceased  hot 


660  DISEASES    OF    THE    PROSTATE. 

poultices  or  fomentations  may  be  applied  to  the  perineum.  Ice  has  been 
advocated,  rectal  suppositories  of  ice  being  sometimes  useful.  Hot  water 
containing  laudanum  is  often  serviceable  as  an  enema.  Simple  hot  ene- 
mata,  several  quarts  of  water  being  used  at  each  sitting,  may  be  given  sev- 
eral times  daily  with  great  advantage. 

Interference  with  the  urethra  should  be  avoided,  the  usual  treatment 
for  gonorrhea  being  suspended  during  the  course  of  the  prostatitis.  The  use 
of  injections  may  determine  the  formation  of  an  abscess  in  an  otherwise- 
slight  inflammation. 

Hot  sitz-baths,  twice  or  thrice  daily,  are  of  marked  benefit  in  pros- 
tatitis. They  must  be  very  hot  and  continued  for  from  half  an  hour  to  an 
hour.  Should  retention  occur  and  opium  and  hot  sitz-baths  fail  to  relieve, 
then,  and  then  only,  is  catheterism  permissible.  A  small,  soft  catheter  should 
be  carefully  used.  This  failing,  aspiration  may  be  required.  Eectal  exam- 
inations should  be  made  as  infrequently  as  possible.  The  surgeon  is  usually 
overanxious  to  observe  the  progress  of  the  case  and  in  his  misplaced  enthu- 
siasm is  apt  to  do  injury.  As  the  acuteness  of  the  inflammation  becomes 
less  manifest,  counter-irritation  with  iodin  or  blisters  to  the  perineum  may 
be  of  great  service.  Systematic  and  repeated  blistering  may  perhaps  pre- 
vent the  supervention  of  chronic  inflammation. 

Under  careful  treatment  the  inflammation  usually  begins  to  subside 
and  the  symptoms  improve  within  a  few  days,  but  it  is  likely  to  be  several 
months  before  the  prostate  assumes  anything  like  its  normal  size.  The 
slightest  excess  is  apt  to  cause  a  relapse,  and  the  patient  is  ever  after  pre- 
disposed to  fresh  attacks  of  inflammation — reinfection — ^from  apparently 
trivial  causes.  Slight  indiscretions  are  liable  to  prevent  resolution  and 
cause  the  inflammatory  process  to  become  chronic.  Prostatitis  may  conse- 
quently be  a  very  unsatisfactory  affection  to  treat,  even  in  the  most  tract- 
able and  conscientious  patient.  Eecurrent  infection  of  the  urethra  simu- 
lating a  fresh  gonorrhea  is  one  of  the  most  annoying  features  of  the  disease. 

In  a  general  way  the  liability  to  suppuration  in  acute  prostatitis  de- 
pends upon  the  degree  of  thoroughness  with  which  the  foregoing  measures 
are  carried  out.  Where  the  inflammation  is  due  to  the  absorption  of  pus- 
microbes  and  their  products  through  the  medium  of  an  abrasion  or  via 
the  lymphatics  without  abrasion,  with  resulting  interstitial  prostatic  in- 
fection, suppuration  is  almost  inevitable.  In  the  ordinary  diffuse  form 
of  inflammation,  however,  and  in  the  follicular  form  which  precedes  it, 
energetic  treatment  may  prevent  abscess. 

The  treatment  of  acute  abscess  of  the  prostate  is  obviously  that  of  acute 
prostatitis.  Until  pus  is  known  to  have  formed  or  a  strong  suspicion  of  its 
presence  is  justifiable,  surgical  intervention  is  contra-indicated.  "While  con- 
servative treatment  by  means  of  poultices  to  the  perineum  and  rectal  injec- 
tions of  hot  water  may  be  justifiable  in  cases  in  which  the  presence  of  pus 
is  extremely  doubtful,  the  practitioner  should  beware  of  carrying  conserva- 


TEEATMEXT    OF    PEOSTATIC    SUPPUEATIOX.  661 

tism  too  far.  Serious  results  occur  from  a  large  accumulation  of  pus  in  and 
about  the  prostate  long  before  fluctuation  is  manifest.  Fluctuation  should 
always  be  carefull}^  sought  for,  but  in  many  cases  operation  is  demanded 
long  before  perineal  fluctuation  can  be  detected.  When  the  abscess  involves 
the  periprostatic  tissue  or  burrows  toward  the  rectum,  digital  examination 
via  the  gut  is  likely  to  detect  either  well-marked  fluctuation  or  the  peculiar 
edematous  condition  characteristic  of  the  presence  of  pus. 

As  soon  as  the  diagnosis  of  abscess  is  justified  by  the  development  of 
perineal  induration  and  swelling,  characteristic  edema,  or  distinct  fluctua- 
tion on  rectal  examination,  a  free  incision  in  the  direction  of  the  prostate 
should  be  made  in  the  perineal  raphe.  This  locality  should  always  be  se- 
lected even  where  well-marked  fluctuation  on  rectal  examination  indicates 
the  presence  of  pus  in  the  periprostatic  tissue.  If  pus  is  not  found  by  the 
perineal  incision,  the  surgeon  can  console  himself  with  the  reflection  that  he 
has  adopted  the  best  means  possible  to  prevent  abscess.  Should  suppura- 
tion eventually  occur  the  incision  supplies  an  outlet  in  the  most  favorable 
direction.  If  several  foci  of  suppuration  be  found  they  should  be  freely 
opened  and  drained.  lodoform-gauze  drainage  should  be  adopted  after 
evacuation  of  the  pus.  Infiltration  of  urine  may  possibly  occur  after  the 
opening  of  prostatic  abscess,  but  is  very  rare. 

When  a  prostatic  or  periprostatic  abscess  is  opened  or  discharges  spon- 
taneously via  the  rectum,  extensive  infection,  with  the  formation  of  ischio- 
rectal abscess  and  external  fistula  or  a  permanent  internal  fistula,  may  re- 
sult. In  all  cases  in  which  the  abscess  has  been  evacuated  into  the  rectum 
antiseptic  irrigation  is  necessary.  Care  should  be  taken,  however,  to  avoid 
poisoning  the  patient  by  too-strong  antiseptic  solutions.  Carbolic  acid  and 
mercury  bichlorid  are  especially  open  to  impeachment  on  this  score.  A 
saturated  solution  of  boric  acid  is  much  safer,  although  necessarily  not  so 
efficient.  It  may  become  necessary  to  divulse  the  sphincter  ani  to  relieve 
rectal  tenesmus  or  secure  perfect  drainage.  By  putting  the  sphincter  at 
rest  it  may  be  possible  to  induce  healing  without  the  necessity  of  more 
serious  operative  procedures.  In  the  event,  however,  that  a  permanent 
fistula  results,  it  should  be  dealt  with  as  in  ordinary  cases  of  ano-rectal 
fistula.  When  the  abscess  ruptures,  or  is  evacuated  by  the  perineal  route, 
there  is  danger  of  permanent  urinary  fistula.  When  the  pus  is  evacuated 
in  the  direction  of  the  urethra,  the  repeated  formation  of  deep  periurethral 
abscesses  may  eventually  result  in  perineal  fistula. 

When  the  pus  is  external  to  the  prostate  in  the  paraprostatic  tissue, 
there  is  less  danger  of  infiltration  of  urine  and  urinary  fistula  than  in  cases 
in  which  the  prostate  proper  is  involved. 

General  supportive  measures  and  possibly  the  administration  of  stimu- 
lants may  be  necessary  after  the  evacuation  of  a  prostatic  abscess.  This 
course  should  be  invariably  adopted  in  cases  of  prostatic  abscess  in  pros- 
tatiques.    Should  general  pus-infection  occur  in  the  course  of  prostatic  ab- 


663  DISEASES    OF    THE    PROSTATE. 

scess,  as  it  is  likely  to  do  in  old,  cachectic,  and  debilitated  subjects,  death  is 
practically  inevitable.  In  retention  from  prostatic  inflammation  or  abscess, 
especially  in  old  subjects,  it  may  be  impossible  to  evacuate  the  urine  with 
the  ordinary  catheter.  The  catheter  coude  of  Mercier  may  be  introduced 
much  more  readily  than  the  ordinary  variety.  The  soft  Nelaton  catheter  is 
often  unsatisfactory.  In  passing  the  elbowed  catheter  the  superior  urethral 
wall  is  so  closely  hugged  by  the  beak  of  the  instrument  that  there  is  com- 
paratively little  danger  of  its  penetrating  the  abscess-cavity.  Instances 
have  been  known  where  the  cavity  of  the  abscess  has  thus  been  penetrated 
and  mistaken  for  the  bladder.  The  important  fact  to  be  remembered  is 
that  it  is  far  better  to  evacuate  an  abscess  by  external  incision  than  to 
produce  an  internal  opening  into  the  urethra  or  allow  such  an  opening  to 
occur  spontaneousl3^  It  is  admitted  that,  in  many  cases  in  which  the  ab- 
scess opens  in  the  direction  of  the  urethra,  the  patient  speedily  recovers, 
but  in  a  certain  proportion  of  cases  permanent  infection  results,  with  all 
the  dangers  of  urethritis,  cystitis,  and  recurrent  prostatic  abscesses. 

In  all  cases  of  prostatitis  after  the  acute  symptoms  have  subsided  deep 
urethral  and  vesical  irrigations  are  necessary  for  some  time  to  remove  the 
infection  upon  which  the  prostatic  inflammation  depended  and  which  may 
bring  about  its  recurrence. 


CHAPTEE  XXYIII. 
Chronic  Peostatic  Inflammatiox  and  Suppueation. 


CoNSiDEEiNG  the  frequency  of  chronic  infiammation  of  the  prostate, 
it  is  rather  remarkable  that  it  was  practically  unrecognized  until  the  early 
part  of  the  present  century.  It  must  be  acknowledged  moreover,  that  con- 
siderable confusion  on  this  subject  exists  in  the  minds  of  clinicians  even  at 
the  present  day. 

Vaeieties. — Chronic  prostatitis  presents  itself  in  three  forms,  viz.: — 

1.  The  follicular  or  parenchymatous,  involving  chiefly  the  glandular 
tissvies  of  the  organ. 

2.  The  diffuse,  involving  the  lymphatics,  connective  and  muscular  tis- 
sues of  the  prostate  proper,  and  also,  as  a  rule,  the  seminal  vesicles,  vasa 
deferentia,  and  paraprostatic  tissue. 

3.  The  suppurative. 

ETIOLOGY. 

'  Masturbation. 
Ungratified  sexual  desire. 
Sexual  excess. 
Passage  of  instruments. 
Urethral  or  bladder  disease, 
p  \  Prostatic  hypertrophy. 

Chronic       )  Ano-rectal  disease, 
hyperemia  (  Constipation,    with    consequent    straining    at 
due  to        1         stool. 

Frequent  defecation  in  chronic  diarrhea  and 

dysentery. 
Overexertion. 

Bicycling  and  horseback-riding. 
Dietetic  and  alcoholic  excesses. 
\ Exposure  to  cold. 


Predisposing 

causes 


Diatheses      |  G-out}^,  rheumatic,  and  tubercular. 


(663) 


664:  CHEONIC    PEOSTATIO   INFLAMMATION   AND    SUPPUEATION. 


Aeute  inflammation  from  any  cause,  usually  from  infec- 
tion. 

Repeated  traumatism  from  urethral  instrumentation  or 
external  blows. 

Infection  from  instrumentation. 

Gradual  extension  of  chronic  inflammation  from  the  ure- 
thra or  bladder. 

Infection  by  the  products  of  cystitis. 

Infection  by  the  bacillus  tuberculosis. 

Infection  by  pus-microbes  without  traumatism. 

Eepeated  overstimulation  by  irritant  applications  to  the 
prostatic  urethra. 

Overstimulation  by  drugs  taken  internally,  as  canthar- 
ides,  turpentine,  etc. 


Exciting  causes 


It  is  hardly  necessary  to  expatiate  upon  the  role  of  hyperemia  in  the 
etiology  of  chronic  prostatitis.  It  is  not  likely  that  any  of  the  factors  enu- 
merated as  predisposing  causes  can,  when  acting  alone,  produce  the  disease. 
Several  of  them  taken  together  may,  however,  act  as  exciting  causes.  Thus, 
sexual  excess  and  alcoholism  in  combination  with  the  gouty  or  rheumatic 
diathesis,  particularly  if  associated  with  frequent  exposure  to  cold,  may  pro- 
duce chronic  prostatitis.  It  must  be  remembered,  however,  that  in  by  far 
the  majority  of  cases  in  which  these  factors  are  apparently  responsible  for 
the  chronic  inflammation  there  is  some  source  of  infection  or  direct  irrita- 
tion of  the  prostate.  The  more  carefully  these  cases  are  studied,  the  more 
essential  infection  appears  to  be  in  the  causation  of  chronic  prostatitis,  this 
being  especially  true  of  the  follicular  form.  It  is  not  denied  that  cases  of 
chronic  diffuse  prostatitis  are  met  with,  especially  in  middle-aged  men, 
where  no  history  of  gonorrheal  or  instrumental  infection  can  be  elicited. 
Careful  investigation,  however,  determines  some  source  of  infection  in  by 
far  the  majority  of  cases.  The  possibility  of  autoinfection  from  deep  ure- 
thral catarrh  brought  on  by  the  numerous  predisposing  factors  that  have 
been  outlined  is  here  to  be  taken  into  consideration.  Middle-aged  patients 
presenting  themselves  with  symptoms  of  prostatic  disease,  and  in  whom 
an  enlarged,  moderately  soft,  tender,  and  obviously  inflamed  prostate  is 
found,  are  usually  gouty  or  rheumatic,  high-livers,  and,  as  a  rule,  acknowl- 
edge sexual  excesses.  That  such  a  condition  is  a  foimdation  for  senile  hy- 
pertrophy of  the  prostate  is  highly  probable.  In  some  instances  the  devel- 
opment of  chronic  inflammation,  particularly  of  the  interstitial  variety,  is 
so  insidious  that  the  patient's  attention  is  not  directed  to  the  condition  until 
many  years  after  its  inception.  He  may  or  may  not  recall  a  gonorrhea  oc- 
curring during  his  years  of  indiscretion.  If  he  does  recall  it,  it  is  generally 
with  the  idea  that  he  was  perfectly  restored  to  health  after  the  gonorrhea. 


CHRONIC    FOLLICULAR   PROSTATITIS.  665 

when,  in  reality,  the  foundation  for  Ms  later  trouble  was  laid  at  that  time. 
Cases  are  occasionally  met  with,  on  the  other  hand,  in  which  a  history  of 
continuous  vesical  irritation  is  related,  and  referred  by  the  patient  to  his 
old-time  gonorrhea. 

The  injudicious  passage  of  instruments  into  the  bladder  is  often  re- 
sponsible for  chronic  prostatitis.  Instrumentation  acts  in  two  ways:  1. 
By  producing  mechanic  irritation  and  hyperemia  or  even  abrasion.  2.  By 
carrying  infection  from  the  anterior  urethra  to  the  deeper  parts  of  the  canal. 
The  hyperemia  excited  by  instrumentation  supplies  the  necessary  suscepti- 
bility to  germ-infection.  The  microbes  and  their  products  conveyed  by  the 
instruments  thus  have  an  excellent  culture-bed  prepared  for  them. 

Irritation  of  the  lower  bowel  and  the  bruising  incidental  to  chronic 
constipation  or  frequent  defecation  in  bowel  disease  are  potent  factors  in 
the  production  of  chronic  prostatitis.  The  slightest  infection  or  exposure 
superadded  to  the  irritation  and  hyperemia  already  existing  is  likely  to  set 
up  a  low  grade  of  inflammation  that  usually  becomes  chronic.  The  same 
may  be  stated  regarding  the  effects  of  excessive  indulgence  in  bicycling  and 
horseback-riding. 

The  exciting  causes  of  chronic  prostatitis  that  have  been  enumerated 
are,  with  few  exceptions,  effective  only  through  the  medium  of  infection. 
Even  in  the  case  of  repeated  overstimulation  of  the  prostatic  urethra  by 
irritant  drugs  infection  may  play  a  very  important  role;  secondary,  it  is 
true,  but  none  the  less  important.  Infection,  however,  in  such  cases  is 
probably  not  absolutely  necessary  to  the  production  of  inflammation.  In 
suppurative  prostatitis  it  is  obvious  that  pus-microbes  play  the  most  im- 
portant part.  The  pyogenic  organisms  may  enter  the  organ  via  its  ducts 
and  glands  or  by  lymphatic  absorption.  Lymphatic  absorption  is  generally 
precipitated  by  traumatic  abrasion  of  some  portion  of  the  urethral  tract, 
most  generally  the  prostatic  portion.  It  may,  however,  in  all  probability 
occur  through  the  intact  mucous  membrane.  That  it  may  occur  via  the 
general  circulation  is  occasionally  shown  in  variola,  measles,  and  parotiditis. 
In  such  cases  the  suppurative  process  is  generally  acute.  It  may,  however, 
be  chronic  and  is  very  likely  to  be  unrecognized  until  serious  damage  has 
resulted.  A  fatal  issue  without  special  symptoms  referable  to  the  prostate 
is  possible. 

Chronic  Follicular  or  Parenchymatous  Prostatitis. — The  no- 
menclature of  this  variety  is  based  upon  the  proposition  advanced  in  the 
consideration  of  acute  follicular  prostatitis,  viz.:  that  the  secreting  glandu- 
lar structures  and  ducts  of  the  prostate  constitute  its  essential  anatomic 
elements  and  should  therefore  be  regarded  as  its  true  parenchyma.  Chronic 
parenchymatous  prostatitis  necessarily  involves  the  glandular  structures  of 
the  organ  and  usually  the  prostatic  urethra,  the  latter  being  the  point  of 
departure  of  the  inflammation  in  nearly,  if  not  quite,  all  cases.  The  mu- 
cous membrane  of  the  prostatic  urethra  may  eventually  become  approxi- 


666  CHKOXIC    PKOSTATIC    IXFLAMMATIOX    AXD    SUPPL'EATIOX. 

mately  normal,  while  the  glandular  inflammation  continues  indefinitely. 
Chronic  follicular  or  parenchymatous  prostatitis  embraces  a  variety  of  er- 
roneously diagnosed  affections.  Cystitis,  urethral  stricture,  neuralgia  of 
the  vesical  neck,  posterior  urethritis,  prostatorrhea,  spermatorrhea,  and  ca- 
tarrh of  the  bladder  constitute  some  of  the  diagnoses  under  which  chronic 
follicular  prostatitis  is  likely  to  masquerade.  The  disease  is  often  associated 
with  a  certain  amount  of  chronic  diffuse  inflammation.  Many  cases  are 
met  with  in  which  the  glandular  inflammation  is  the  essential  condition, 
the  interstitial  involvement  being  a  subordinate  and  apparently  secondary 
feature.  In  some  instances  chronic  parenchymatous  j)rostatitis  has  been 
preceded  by  well-marked  acute  parenchymatous  inflammation  associated 
■«ath  difl'use  involvement  of  the  prostatic  tissue,  yet  the  interstitial  inflam- 
mation has  practically  subsided  without  appreciable  improvement  in  the 
glandular  inflammation.  As  already  remarked  in  connection  with  acute 
follicular  prostatitis,  this  variety  of  inflammation  has  a  greater  tendency 
toward  chronicity  than  the  interstitial. 

Chronic  follicular  prostatitis  is  generally  due  to  infection  and  usually 
follows  acute  inflammation.  In  most  cases  the  patient  gives  a  history  of 
gonorrhea  with  some  complication  that  has  been  referred  to  the  deep  ure- 
thra, bladder,  or  prostate.  Broadly  speaking,  a  patient  who  does  not  give 
a  history  of  some  acute  disturbance  of  the  function  of  micturition  during 
the  course  of  a  gonorrhea  is  not  very  likely  to  be  suffering  from  this  form 
of  prostatic  inflammation.  If,  however,  such  a  history  be  given,  it  is  safe 
to  infer  that  some  morbid  condition  of  the  prostate  is  still  present.  The 
exceptions  to  this  rule  the  author  believes  to  be  rare.  In  some  few  instances, 
perhaps,  the  deep  urethra  becomes  infected  and  the  inflammatory  process 
limits  itself  to  the  pars  membranosa.  Such  cases,  however,  must  be  ex- 
ceptional. In  a  large  majority  of  instances  of  deep  infection  the  prostatic 
urethra  and  almost  inevitably  the  glandular  structures  of  the  prostate 
become  involved  sooner  or  later.  Once  the  prostate  is  infected,  whether 
diffuse  inflammation  develops  or  not,  it  is  the  author's  firm  conviction  that 
restoration  to  a  normal  condition  never  thereafter  occurs.  The  frequency 
of  chronic  prostatitis  is  much  greater  than  generally  believed.  This  may  be 
demonstrated  by  careful  dissection  of  prostates  taken  at  random,  especially 
among  hospital  j^atients. 

^Yhen  we  consider  the  multitudinous  glands  and  ramifications  of  ducts 
constituting  the  most  important  structure  of  the  prostate,  and  the  poor 
facilities  for  drainage  afforded  these  tissues,  the  prolonged  duration  of  in- 
fectious processes  is  by  no  means  remarkable.  The  subjective  signs  of  pro- 
static inflammation  depend  largely  upon  the  degree  and  duration  of  the  in- 
flammation of  the  prostatic  urethra.  The  objective  signs  depend  mainly 
on  the  degree  of  interstitial  involvement.  Careful  examination  may  fail  to 
detect  any  alteration  in  the  size,  consistency,  form,  and  sensibility  of  the 
prostate,   even  when  well-marked   chronic   follicular   inflammation   exists. 


SYMPTOMS    OF    CHRONIC    FOLLICULAR   PROSTATITIS.  667 

The  urinary  symptoms  having  subsided  and  the  prostate  having  apparently 
assumed  its  normal  condition,  so  far  as  rectal  examination  enables  us  to 
determine,  it  will  still  be  found  that  upon  the  slightest  indiscretion  or  ex- 
posure vesical  irritation  and  tenesmus  develop,  which  usually  pass  as  ex- 
acerbations of  cystitis. 

Symptoms. — The  patient  usually  gives  a  history  of  more  or  less  recent 
gonorrhea  with  complicating  deep-seated  inflammation  referred  to  the 
posterior  urethra,  bladder,  or  prostate  according  to  the  notion  of  the  phy- 
sician who  has  happened  to  have  the  case  in  hand.  There  is  often  a  his- 
tory of  complicating  epididymitis  that  is,  in  itself,  trustworthy  evidence 
of  prostato-urethral  inflammation.  The  symptoms  of  vesical  irritation  at 
the  neck  characteristic  of  follicular  or  parenchymatous  prostatitis  may 
have  subsided  and  the  patient  may  assert  that  he  has  been  perfectly  well 
for  some  little  time,  a  relapse  having  been  brought  on  by  indiscretion  or 
exposure  to  cold.  On  careful  questioning,  however,  it  will  be  found  that 
slight  symptoms  referable  to  the  neck  of  the  bladder  and  the  region  of  the 
prostate,  consisting  of  more  or  less  weight,  voluptuous  sensations  with  slight 
increase  in  the  frequency  of  micturition,  and,  in  a  general  way,  symptoms 
of  hyperesthesia  of  the  prostatic  urethra,  have  persisted  since  the  original 
acute  inflammation.  In  other  instances  the  patient  gives  a  history  of  con- 
tinuous vesical  irritation  of  greater  or  less  severity  since  the  primary 
involvement  of  the  prostatic  urethra.  The  principal  symptoms  are  fre- 
quency of  micturition  with  more  or  less  pain  and  perhaps  a  slight  quan- 
tity of  blood  at  the  termination  of  the  act  as  the  deep  perineal  muscles 
contract  upon  the  tender  prostate.  The  urinary  symptoms  in  general 
are  not  unlike  those  of  vesical  calculus.  The  sexual  function  is  more 
or  less  disturbed.  Nocturnal  pollutions,  premature  and  perhaps  painful 
ejaculations  may  exist.  The  seminal  discharges  may  be  mixed  with  a 
greater  or  less  quantity  of  blood,  especially  if  the  seminal  vesicles  are  in- 
volved. A  sensation  of  fullness  with  perhaps  a  tinge  of  voluptuous  sensa- 
tion in  the  perineum,  itching  and  tickling  sensations  in  the  perineum,  ure- 
thra, anus,  and  rectum  are  frequent.  There  may  be  frequent  and  persistent 
erections  and  excessive  sexual  desire.  Patients  sometimes  go  to  the  other 
extreme  and  complain  of  complete  loss  of  sexual  appetite  and  power.  More 
or  less  congestion  or  inflammation  of  the  anterior  urethra  is  likely  to  exist, 
either  as  a  consequence  of  simple  irritation  and  circulatory  disturbance  or 
infection  from  the  deeper  portion  of  the  canal;  as  a  consequence  there  is 
more  or  less  oozing  of  muco-purulent  discharge  from  the  meatus.  This  is 
most  profuse  during  defecation  and  at  the  end  of  micturition,  and  may  be 
noticeable  only  at  such  times.  It  is  to  be  distinctly  understood  that  when- 
ever discharge  appears  from  the  meatus  during  the  intervals  of  micturition 
and  defecation  some  morbid  condition  of  the  anterior  urethra  necessarily 
exists.  More  or  less  backache  with  neuralgic  pains  along  the  spermatic 
cord,  in  the  testes,  groins,  thighs,  and  radiating  into  the  urethra  may  exist. 


668  CHEOXIC   PEOSTATIC    INFLAMMATION   AND    SUPPUEATION. 

The  patient  is  quite  likely  to  complain  of  pain  located  an  inch  or  so  behind 
the  meatus  on  the  under  surface  of  the  urethra.  This  is  apt  to  be  mislead- 
ing both  to  the  patient  and  practitioner,  and  is  ver}^  similar  to  that  experi- 
enced in  vesical  calculus.  The  mind  of  the  patient  is  rarely  tranquil,  and 
he  is  usually  imbued  with  the  idea  that  he  has  spermatorrhea.  The  dis- 
charge may  contain  spermatozoa  where  the  stool  is  difficult  and  much  press- 
ure is  brought  to  bear  upon  the  seminal  vesicles;  as  a  rule,  however,  it  is 
muco-purulent  in  character  and  composed  of  pus,  mucus,  and  fatty  detritus 
with  more  or  less  epithelium.  Where  the  vesical  neck  is  profoundly  im- 
plicated the  peculiar  ovoid  epithelium  characteristic  of  this  location  is  apt 
to  be  found.  The  urine  contains  muco-pus  and  epithelium,  the  characters 
varjdng  with  the  degree  of  posterior  urethritis  present.  The  so-called  trip- 
per-fdden  and  the  peculiar  horseshoe-nail-shaped  filaments  or  flocculi  char- 
acteristic of  inflammation  of  the  prostatic  follicles  are  usually  found.  Ex- 
ercise increases  the  symptoms;  there  is  more  or  less  discomfort  attending 
the  act  of  defecation,  and  the  patient  is  very  likely  to  apply  for  relief  for 
rectal  and  anal  disease,  his  symptoms  being  almost  altogether  referable  to 
this  region.  If  the  prostatic  trouble  be  complicated  by  piles,  fissure,  or 
fistula,  an  erroneous  diagnosis  is  quite  likely  to  be  made;  especially  is  there 
an  interdependence  between  the  condition  of  the  prostate  and  that  of  the 
ano-rectal  region.  The  author  has  at  present  under  observation  a  patient 
who  states  that  there  is  a  very  peculiar  oscillation  in  his  symptoms.  When 
the  symptoms  referable  to  the  neck  of  the  bladder  and  prostate  are  most 
severe  there  is  less  discomfort  in  the  region  of  the  rectum,  and  vice  versa. 
As  has  already  been  asserted,  the  parenchymatous  form  of  the  disease 
is  apt  to  be  associated  with  a  greater  or  less  degree  of  diffuse  inflammation. 
The  severity  of  the  symptoms  is  in  direct  proportion  to  the  degree  of  dif- 
fuse inflammation  present  in  cases  in  which  the  two  conditions  are  asso- 
ciated. The  symptoms  of  the  diffiise  form  are  obviously  essentially  the 
same  as  those  already  outlined,  with  certain  exceptions,  due  to  a  difference 
in  etiology.  Where  the  glandular  inflammation  follows  acute  infection, 
which  usually  occurs  in  comparatively  young  subjects,  the  principal  con- 
dition is  one  of  chronic  inflammation  of  the  glands  and  ducts  of  the  pros- 
tate, and  the  disturbance  of  the  urinary  and  sexual  functions  is  more  marked 
than  in  cases  occurring  in  middle-aged  men  in  whom  the  gouty  or  rheu- 
matic diathesis,  high  living,  excesses,  and  a  comparatively  mild  infection 
are  responsible  for  the  condition  present.  In  these  patients  the  urinary 
symptoms  may  be  comparatively  mild  -until  such  time  as  mechanic  dis- 
turbance of  the  function  of  micturition  supervenes.  In  these  cases,  too, 
discharge  may  not  be  present,  although  the  urine  may  give  evidence  of  a 
low  grade  of  chronic  inflammation  of  the  prostatic  urethra.  In  some  in- 
stances there  is  not  only  no  discharge,  but  the  urine  is  normal.  While  in 
parench}Tnatous  prostatitis  there  may  be  little  or  no  enlargement  of  the 
pro&tate,  in  the  variety  at  present  under  consideration  it  is  distinctly  and 


MOEBID    ANATOMY    OF    CHKOXIC    PROSTATITIS.  669 

sometimes  considerably  enlarged.  In  both,  forms  of  tbe  disease  there  is 
more  or  less  tenderness  upon  pressure  in  the  perineum,  and  decided  tender- 
ness with  urgent  desire  to  micturate  on  digital  pressure  via  the  rectum. 

The  psychic  disturbance  in  middle-aged  subjects  with  diffuse  chronic 
inflammation  of  the  prostate  is  either  subordinate  or  entirely  absent.  Aber- 
rations of  the  sexual  functions,  however,  are  frequently  met  with,  although 
they  are  not  likely  to  be  regarded  by  the  patient  with  the  solicitude  char- 
acteristic of  younger  men.  Digital  examination  is  likely  to  show  in  these 
cases  thickening,  and  perhaps  tenderness  of  the  seminal  vesicles  and  vasa 
deferentia.  This  diffuse  hyperplasia  may  be  mistaken  for  the  condition  of 
arteriosclerosis  so  strenuously  insisted  upon  by  Guyon  and  his  school  as  the 
essential  feature  of  prostatic  hypertrophy;  indeed,  it  may  perhaps  lead  to 
interstitial  fibrosis.  That  chronic  diffuse  inflammation  is  the  foundation  for 
many  cases  diagnosed  as  hypertrophy  of  the  prostate  the  author  is  firmly 
convinced;  that  such  chronic  inflammation  may  result  from  abuse  of  the 
organ,  not  only  by  high  living,  but  by  oversexual  indulgence  in  early  life, 
the  author  also  believes. 

Morbid  Anatomy. — About  thirty  years  ago  the  elder  Gross  said  that 
the  morbid  anatomy  of  chronic  prostatitis  was  something  which  did  not  exist. 
If  we  were  to  accept  many  of  the  so-called  cases  of  prostatorrhea  as  chronic 
prostatitis  the  opinion  of  this  distinguished  surgeon  might  still  be  accepted 
as  authoritative.  As  already  indicated,  however,  a  large  proportion  of  these 
cases  should  not  be  termed  chronic  prostatitis,  consisting,  as  they  do,  merely 
of  hyperemia  of  the  prostate  with  attendant  hypersecretion.  Inasmuch  as 
chronic  prostatitis  is  not  essentially  fatal,  opportunities  for  its  post-mortem 
study  are  relatively  rare.  A  sufficient  number  of  observations  have  been 
made,  however,  to  prove  that  chronic  prostatitis  not  only  exists  as  a  patho- 
logic entity,  but  that  its  morbid  anatomy  is  well  marked. 

In  chronic  follicular — i.e.,  parenchymatous — -prostatitis  there  may  be 
little  or  no  alteration  in  the  prostate  body,  as  shown  on  clinical  examina- 
tion, yet  post-mortem  section  of  the  tissue  shows  an  increased  consistency 
of  the  prostatic  tissue  incidental  to  more  or  less  periglandular  thickening, 
— i.e.,  interstitial,  connective-tissue  hyperplasia.  This  is  more  marked  in 
middle-aged  patients.  Long  continuance  of  the  glandular  inflammation 
eventually  determines  a  greater  or  less  degree  of  diffuse  chronic  inflamma- 
tion. Diffuse  inflammation,  with  considerable  enlargement  of  the  prostate 
in  men  of  middle  age  is  probably  often  due  to  long-continued  chronic  gland- 
ular inflammation  or  chronic  hyperemia.  Hyperplasia  of  the  epithelium 
lining  the  ducts  and  glands  is  constant.  The  lymphatics  may  be  thickened 
and  hyperplasic.  The  conditions  of  glandular  thickening  and  h^^perplasia 
are  likely  to  lead  to  an  irregularity  of  contour  of  the  prostate  that  may  be  misr 
taken  for  tuberclilosis.  The  follicular  and  racemose  glands  and  their  ducts 
are  often  dilated — irregularly  so,  as  a  rule.  Complete  or  partial  occlusion 
may  occur  here  and  there,  producing  retention-cysts  containing  muco-pus 


670  CHBOXIC  PBOSTATIC   ESTLAJOCATIOX   AXD    SUPPUEATIOX. 

and  epiihelinTTi.  The  urethial  orifices  of  tlie  prostatic  ducts  are  usually 
dilated  and  thickened,  although  their  Itimen  is  sometimes  more  ot  less  con- 
tracted. Pre^nre  upon  the  gland  causes  the  exudation  of  a  muco-punilent 
duid  mixed  with  epithelial  debris.  The  mucous  membrane  of  the  prostatic 
urethra  may  he  normal,  hut  it  is  litely  to  be  thickened,  hyperemic.  and  pos- 
sihly  granular.  This  condition  exists  where  chronic  prostato-urethritis  has 
been  the  chief  feature  of  the  case.  The  foregoing  changes  are  to  be  ex- 
pected in  practically  all  indixiduals  who  have  ever  experienced  acute  in- 
fammation  of  the  prostate.  That  such  changes  are  frequent  the  author 
has  demonstrated  by  a  large  number  of  post-mortem  dissections.  These  dis- 
sections showed  that  well-marked  diffuse  prostatitis  iuTolves  not  only  the 
prostate  body  proper,  but  the  prostatic  urethra,  the  prostatic  glands  and 
ducts,  the  seminal  Tesicles,  xasa  deferentia,  and  the  periprostatic  tissues  iq- 
Testing  the  prostate,  neck  of  the  bladder,  seminal  vesicles,  and  Tas  deferens. 
Thickening  and  induration  of  the  inrolxed  tissues  are  a  marked  feature. 
Desnos  and  Kirmisson  hare  directed  especial  atiention  to  the  thickening  of 
the  submucous  rectal  tissue  contiguous  to  the  prostate  and  of  the  cellular  tis- 
sue lying  between  the  prostate  and  rectum.  Adenitis  with  enlargement  of 
the  lymphatic  glands  and  resulting  nodulation  of  the  prostate — discernible 
from  the  rectum — ^is  more  likely  to  occur  in  diffuse  than  in  follicular  or 
parenchymatous  prostatitis.  This  condition  is  probably  the  one  most  often 
mistaken  for  prostatic  tuberculosis. 

In  suppurative  prostatitis  there  may  be  extreme  dilation  of  the  ducts 
and  racemose  glands,  constituting  an  advanced  stage  of  parenchymatous  in- 
fammation.  The  pseudocysts  are  distended  with  the  products  of  supptira- 
rion — i.e.,  muco-pus  and  epithelial  dihris — ^in  conjunction  with  prostatic 
secretion.  The  prostatic  tissue  may  be  relatively  atrophied  by  pressure 
malnutrition,  while  actual  increase  of  bulk  from  the  neoplastic  formation 
exists.  The  cavities  formed  by  occlusion  of  the  prostatic  ducts  and  glands 
and  accumulation  of  pathologic  products  may  open  into  the  interstitial  tis- 
sue, producing  infection  and  extensive  abscess.  True  abscesses  occur  in 
several  forms,  viz.:  (a)  there  may  be  one  large  abscess  circumscribed  from 
the  beginning  or  formed  by  fusion  of  several  smaller  ptis-cavities;  (&)  dis- 
seminated small  foci  of  suppuration;  (c)  the  periprostatic  tissue  may  be  the 
seat  of  the  abscess.  In  such  cases  a  peripheral  prostatic  abscess  has  in  all 
probability  ruptured  into  the  periprostatic  rissue  and,  produced  secondary 
infection  therein.  Thompson  has  encountered  eases  in  which  several  ab- 
scises from  the  size  of  a  grain  of  sago  to  that  of  a  large  pea  were  found  in 
the  substance  of  the  gland.  The  prostatic  utricle  is  sometimes  dilated  and 
filled  with  pus.  Large  or  small  abscesses  often  communicate  with  the  ure- 
thra, in  which  event  they  are  likely  to  contain  the  products  of  .urinary  de- 
composition. The  abscess-cavity  may  communicate  with  the  rectum,  peri- 
neum, bladder,  or  urethra.  Abscess^  may  be  found  where  no  svmptoms 
of  prostatic  suppuration  existed  during  life.    Civiale  relates  the  case  of  an 


TEEATMENT    OF    CHEO^STIC    PE03TATITIS.  671 

old  man  who^  for  twenty  days,  was  under  careful  observation  in  tlie  Hopital 
Xecker.  There  was  no  suspicion  of  prostatic  abscess,  yet  among  many  seri- 
ous lesions  of  tbe  genito-nrinary  tract  found  upon  autopsy  was  a  large  abscess 
of  the  prostate.  Sucb  abscesses  are  not  infrequently  found  in  almost  any 
chronic  disease  of  the  genito-urinary  tract,  perhaps  most  frequently  in  strict- 
ure of  the  urethra.  Prostatic  suppuration  may  occur  as  a  result  of  infection 
in  cystitis,  prostatic  hjrpertrophy  or  vesical  calculus.  TVhen  suppuration  has 
occurred  in  the  course  of  prostatic  hypertrophy  the  prostate  presents  the  or- 
dinary characters  of  hypertrophy  associated  with  suppuration.  The  prostate 
sometimes  atrophies  completely  under  the  pressure  of  pus,  the  capsule  of 
the  prostate  and  the  periprostatic  tissues  undergoing  fibroid  transformation, 
forming  a  pseudocyst  containing  pus,  perhaps  conununicating  with  the 
prostatic  urethra.  Tubercular  deposits  may  be  found  in  connection  with 
chronic  prostatitis,  which  condition  is  classified  by  some  authors  as  tuber- 
culous prostatitis.  T7nder  such  circumstances  the  abscess  is  due  to  one  or 
both  of  two  conditions,  viz.:  (a)  caseation  of  tubercular  tissue:  (5)  pus- 
infection.  Tubercular  prostatitis  merits  fuller  consideration,  which  will 
be  given  it  in  the  next  chapter. 

It  is  possible  that  in  some  cases  chronic  prostatic  abscess  is  due  to  sup- 
purative adenitis  from  mixed  infection.  Periprostatic  abscess  is  especially 
likely  to  form  in  this  way. 

TEEATiLEifT. — Chronic  foUicular  or  parenchymatous  prostatitis  is  to 
be  regarded  essentially  as  infection  of  the  mucous  membrane  of  the  pro- 
static urethra  and  the  epithelium  lining  the  ducts  and  follicles  of  the  organ. 
Its  treatment  is  largely  that  of  so-called  posterior  chronic  urethritis.  It  is  to 
be  remembered,  however,  that  in  some  instances  the  prostatic  mucous  mem- 
brane becomes  comparatively  healthy,  while  the  infections  process  and  its 
results  in  the  glandular  structures  of  the  organ  persist  indefinitely.  By 
regarding  the  condition  as  chronic  follicular  prostatitis  rather  than  posterior 
urethritis  it  is  likely  to  be  treated  upon  more  logical  principles  than  at  the 
hands  of  those  who  beKeve  that  the  infectious  process  limits  itself  to  the 
posterior  or  prostatic  urethra  alone. 

The  therapeutics  of  the  disease  may  be  divided  for  consideration 
into : — 

r  Hygienic  and  dietetic  measures. 

(A)  General  J  Eemedies  having  a  special  action  on  the  genito-nrinary  tract. 

I  Eemedies  to  correct  diathetic  conditions. 

Mechanic  treatment  by  sounds  and  massage. 
Irrigations. 

(B)  Local     ^    InstiQations. 

I    Medicinal  applications  by  ointments  or  soluble  bougies. 
[^  Counter-irritation. 


672  CHEOXIC    PKOSTATIO    II>rFLAMMATION   AND    SUPPUEATION. 

The  general  treatment  should  comprise  careful  attention  to  genito- 
urinary hygiene,  with  especial  reference  to  the  sexual  function,  and  the  ad- 
ministration of  remedies  having  more  or  less  marked  special  action  upon 
the  prostate  and  the  genito-urinary  mucous  membrane.  There  is  little 
hope  of  securing  much  benefit  from  treatment  unless  the  patient  leads  a 
life  of  continence  and  dietetic  temperance.  While  from  a  pathologic  stand- 
point a  perfect  cure  of  chronic  prostatitis  rarely,  if  ever,  occurs,  the  patient, 
in  a  large  proportion  of  cases,  may  become  practically  well  if  due  considera- 
tion be  paid  to  the  time-element  in  treatment  and  judicious  instruction  in 
genito-urinary  and  sexual  hygiene  be  given  and  conscientiously  followed. 

Dilation  of  the  prostate  by  means  of  the  steel  sound  is  curative  in  a 
certain  proportion  of  cases  where  the  inflammation  is  chiefly  parenchyma- 
tous or  follicular.  Caution  is  necessary  in  selecting  the  time  for  beginning 
the  use  of  the  sound.  It  is  likely  to  be  injurious  before  the  primary  acute 
inflammation  has  subsided.  It  is  by  no  means  unusual  for  the  early  use  of 
the  sound  to  excite  a  recurrence  of  acute  inflammation.  Should  penile  strict- 
ure exist,  urethrotomy  is  usually  indicated.  Stricture  at  or  near  the  meatus 
is  especially  liable  to  aggravate  prostatic  inflammation  on  account  of  the 
reflex  irritation  and  hyperemia  it  excites  in  the  deep  urethra  and  its  mus- 
cular environment.  In  such  cases  the  first  indication  is  to  free  the  ante- 
rior urethra  of  all  points  of  irritation  and  contraction.  Many  previously 
rebellious  cases  of  chronic  prostatitis  yield  very  speedily  after  internal  ure- 
throtomy. The  results  of  the  operation  in  these  cases  are  sometimes  ex- 
tremely gratifying.  The  author  desires  to  call  especial  attention  to  this 
feature  of  certain  cases  of  chronic  prostatitis. 

Inasmuch  as  in  a  majority  of  cases  of  chronic  prostatic  inflammation 
there  exists,  either  primarily  or  secondarily,  infectious  inflammation  of  the 
prostatic  urethra  and  the  glands  and  ducts  tributary  to  it,  some  form  of 
antiseptic  treatment  is  indicated.  Internal  medication  with  eucalyptus  and 
balsamic  preparations  aids  somewhat  in  antisepsis  of  the  prostatic  urethra, 
but  more  direct  measures  are  usually  necessary.  Where  it  is  possible  to  em- 
ploy it,  deep  irrigation  via  a  short  urethral  nozzle  is  best.  In  most  patients, 
after  a  little  training,  water  can  be  readily  forced  from  the  anterior  into 
the  deep  urethra  and  bladder  without  the  aid  of  either  catheter  or  irri- 
gating tube.  In  this  manner  alone  can  the  urethra  and  bladder  be  thor- 
oughly irrigated.  There  are  but  three  remedies  which  are  likely  to  prove 
effectual  by  irrigation.  These,  in  order  of  efficiency,  are  potassium  per- 
manganate, silver  nitrate,  and  mercury  bichlorid.  Potassium  permanganate 
may  be  used  in  the  strength  of  from  1  in  5000  to  1  in  1000.  The  water  should 
be  only  comfortably  warm  and  should  be  employed  in  a  quantity  of  not  less 
than  two  quarts  at  each  irrigation.  In  the  larger  proportion  of  cases  the 
potassium  permanganate  is  successful.  Sometimes,  however,  it  has  little 
effect,  in  which  event  silver  nitrate  in  weak  solutions  often  acts  admirably. 
The  solutions  ordinarily  recommended  are  too  strong.     From  ^/^  to  1  per 


TBEATMENT    OF    CHEONIC    PKOSTATITIS.  673 

cent,  is  usually  all  the  urethra  and  bladder  will  tolerate.  It  is  worthy  of  re- 
mark that  a  ^/2-per-cent.  solution  by  irrigation  excites  more  pronounced 
reaction  in  the  deep  urethra  and  bladder  than  much  stronger  solutions  used 
by  instillation.  Where  the  silver  nitrate  fails,  mercury  bichlorid  may  be 
used.  Deep-urethral  instillations  of  antiseptic  and  astringent  remedies  come 
next  in  order.  They  are  highly  extolled  by  many  of  our  genito-urinary  au- 
thorities, though  often  disappointing.  As  used  with  the  ordinary  Ultzmann 
syringe,  the  injection  of  a  few  drops  of  silver-nitrate  solution  into  the  pro- 
static urethra  for  the  cure  of  follicular  prostatitis,  or  so-called  posterior 
urethritis,  is  the  height  of  absurdity.  The  area  medicated  by  the  solution 
is  but  a  small  part  of  that  which  is  infected,  and  a  few  drops  of  a  more 
or  less  powerful  solution  of  silver  nitrate  are  not  likely  to  accomplish  much 
good.  Where  the  instillation  method  is  used  the  syringe  should  hold  a  dram 
or  two  of  fluid.  The  orifices  in  the  injecting  tube  should  be  numerous, 
permitting  the  fluid  to  escape  simultaneously  in  all  directions,  flushing  the 
prostatic  urethra  thoroughly.  Such  a  syringe  is  very  convenient  where  it 
is  desirable  to  leave  a  certain  quantity  of  antiseptic  or  astringent  fluid  in  the 
bladder.  Silver  nitrate,  mercury  bichlorid,  thallin  sulphate,  protargol,  and 
zinc  chlorid  are  the  most  reliable  of  the  remedies  in  vogue  for  instillation. 
Astringent  and  antiseptic  remedies  applied  in  the  form  of  ointments  or  solu- 
ble bougies  are  often  of  service.  Iodoform  is  probably  the  most  valuable 
medicament  for  use  in  this  manner.  Silver  nitrate  in  combination  with 
lanolin  5  to  20  grains  to  the  ounce,  is  frequently  efficacious.  Local  medica- 
tion of  the  prostate  via  the  rectum  is  also  useful.  Iodoform,  europhen,  and 
ichthyol  in  combination  with  anodynes  are  often  efficaciously  used  in  this 
manner,  especially  where  well-marked  diffuse  inflammation  exists.  In  such 
cases,  also,  massage  of  the  prostate  and  seminal  vesicles  via  the  rectum  is 
a  sine  qua  non.  Counter-irritation  of  the  perineum  by  blisters  is  a  valu- 
able adjuvant.  Frequently  repeated  hot  enemata  in  combination  with  hot 
sitz-baths  are  of  service.  In  obstinate  cases  prolonged  rest  in  bed  is  indi- 
cated. Many  cases  of  chronic  inflammation  of  the  prostate  might  be  prac- 
tically cured  by  rest.  Due  attention  should  be  paid  to  the  condition  of  the 
bowels.  Hepatic  torpor  especially  must  be  counteracted.  The  pelvic  cir- 
culation, in  short,  should  be  kept  as  active  as  possible  by  appropriate  reme- 
dies. In  cases  of  severe  diffuse  chronic  inflammation  that  resist  all  other 
measures  a  cure  may  be  effected  in  a  large  proportion  of  instances  by  putting 
the  prostate  and  vesical  neck  completely  at  rest  by  combined  suprapubic 
and  perineal  section  with  through-and-through  drainage.  Perineal  drain- 
age should  be  persisted  in  for  several  weeks,  after  which  time  the  supra- 
pubic opening  alone  is  to  be  relied  upon.  Speedy  subsidence  of  the  prostatic 
inflammation  is  to  be  expected  in  most  cases.  This  method  of  treating 
stubborn  cases  is  especially  successful  in  those  occurring  in  middle-aged 
men. 

Massage  is  by  far  the  most  valuable  therapeutic  procedure  in  all  forms 


674  CHEONIC    PEOSTATIC   INFLAMMATION   AND    SUPPUEATION. 

of  chronic  prostatitis.  It  should  be  practiced  several  times  weekly,  as  a  rule. 
In  some  cases  daily  massage  is  demanded.  It  might  be  well  to  suggest  that 
the  prostate  cannot  be  massaged  through  the  perineum  as  some  physicians 
seem  to  think. 

It  is  unnecessary  to  enumerate  here  the  various  internal  remedies  that 
are  likely  to  prove  of  value.  Anaphrodisiacs,  ergot,  and,  in  brief,  most  of 
the  remedies  that  will  be  suggested  as  useful  in  prostatic  hypertrophy,  and 
some  of  those  recommended  in  acute  inflammation  of  the  organ,  may  be 
beneficial. 

One  of  the  most  important  points  regarding  chronic  inflammation  of 
the  prostate  is  the  fact  that  the  follicular  form  of  gonorrheal  origin  may 
afford  an  infectious  secretion  for  a  prolonged  period.  A  patient  who  has 
been  apparently  well  for  many  months  may  infect  the  female,  not  neces- 
sarily with  true  gonorrhea,  though  this  is  possible,  but  with  some  form  of 
mucous  inflammation  that  is  at  least  a  derivative  of  the  original  specific 
process.  The  patient  should  be  duly  impressed  with  this  feature  of  his  dis- 
ease, that  he  may  appreciate  the  necessity  for  prolonged  treatment  and  strict 
attention  to  hygienic  rules. 

Chronic  suppuration  of  the  prostate  should  be  treated  upon  the  same 
principles  as  abscess  elsewhere.  Evacuation  as  soon  as  detected,  followed 
by  drainage,  and  the  liberal  use  of  tonic  and  dietetic  measures  of  consti- 
tutional support  are  the  main  features  of  treatment. 


CHAPTEE  XXIX. 

Tuberculosis  of  the  Prostate.     Cancer  of  the  Prostate. 
Calculus  of  the  Prostate. 

tuberculosis  of  the  prostate. 

Tuberculosis  of  the  prostate  was  recognized  many  decades  ago  by  the 
great  French  clinician  Louis.  The  first  contribution  clearly  setting  forth 
its  pathologic  anatomy  was  that  of  Verdier.^ 

Since  the  appearance  of  Verdier's  hrochure  many  contributions  upon 
the  subject  have  appeared,  and  tuberculosis,  not  only  of  the  prostate,  but 
of  the  genito-urinary  tract  as  a  whole  has  come  to  be  fairly  well  under- 
stood. The  subject  has  been  much  more  clearly  defined  since  the  establish- 
ment of  the  germ-origin  of  disease.  It  must  be  confessed,  however,  that  the 
knowledge  of  the  possibility  of  primary  and  secondary  tuberculosis  of  the 
prostate  has  added  an  element  of  confusion  to  the  study  and  treatment  of 
prostatic  disease.  As  is  true  of  all  new  fields  of  pathologic  research,  genito- 
urinary tuberculosis  has  become  somewhat  of  a  fad;  it  is  now  quite  fashion- 
able to  classify  most  obstinate  chronic  cases  of  genito-urinary  disease  as 
tubercular — of  which  more  anon. 

Varieties.- — Prostatic  tuberculosis  occurs  in  three  forms  that  are 
clinically  quite  readily  differentiated  where  a  positive  diagnosis  is  possible. 
1.  Primary,  in  which  no  focus  of  infection  more  or  less  distant  is  discover- 
able. In  these  cases  the  tuberculosis  is  usually  ingrafted  upon  chronic 
follicular  inflammation.  Tubercular  disease,  may,  however,  occur  without 
pre-existing  symptoms  of  chronic  inflammation.  2.  Involvement  of  the 
prostate  secondary  to  tuberculosis  in  distant  organs,  the  infection  occurring 
by  way  of  the  general  circulation.  3.  Prostatic  tuberculosis  secondary  to 
disease  of  contiguous  and  correlated  tissues  or  organs.  This  is  the  most  fre- 
quent form.  With  regard  to  the  primary  form,  it  is  questionable  whether 
antecedent  chronic  inflammation  is  not  a  necessary  factor  in  the  etiology. 

Etiology. — In  the  primary  cases  it  is  possible  that  hereditary  or  ac- 
quired tubercular  predisposition  may  exist,  but  the  most  important,  and 
possibly  necessary,  factor  is  the  local  one  of  chronic  follicular  infection. 
That  the  patient's  general  health  is  usually  below  par  is  a  matter  of  almost 
universal  clinical  experience.  In  such  cases  the  point  of  lessened  resistance 
to  bacillary  infection  is  afforded  by  the  long-continued  chronic  inflamma- 
tion. In  some  eases  the  patient  has  either  had  no  antecedent  symptoms  or 
has  been  affected  by  acute  deep-seated  inflammation  of  the  prostate  and 


^  "Observ.  et  refl.  sur  la  phlegmons  de  la  prostate,"  Paris,  1838. 

(675) 


676  TUBERCULOSIS    OF    THE    PllOSTATE. 

posterior  urethra  so  long  since  that  it  seems  unwarrantable  to  attribute 
the  tubercular  infection  to  the  almost-forgotten  gonorrheal  inflammation. 
In  such  cases  it  is  possible  that  the  tubercular  infection  is  not  preceded  by 
chronic  inflammation.  It  is  probable,  however,  that  hyperemia  due  to 
sexual  excess  or  ungratified  desire  and  alcoholism,  or  pelvic  or  prostatic 
congestion  from  whatever  cause,  associated  with  constitutional  debility, 
affords  the  requisite  soil  for  prostatic  infection.  ^More  often  the  pro- 
static tuberculosis  is  secondary  to  tuberculosis  of  associated  organs,  such 
as  the  penis,  testes,  bladder,  seminal  vesicles,  rectum,  or  kidneys.  Sec- 
ondary infection  from  testicular  tuberculosis  is  most  frequent  of  all.  In- 
volvement of  the  prostate  secondary  to  renal  tuberculosis  may  occur  in  two 
ways:  1.  By  the  lodgment  of  the  bacilli  carried  downward  by  the  urine. 
2.  By  infection  via  the  general  circulation  as  in  tuberculosis  of  the  lungs. 
Prostatic  tuberculosis  secondary  to  infection  of  distant  and  unassociated 
organs  is  obviously  not  of  so  great  clinical  importance  as  the  preceding 
varieties,  inasmuch  as  the  primary  infection,  especially  in  the  case  of  the 
lungs  and  peritoneum,  is  usually  intrinsically  fatal.  Prostatic  tuberculosis 
under  such  circumstances  is  of  pathologic  rather  than  clinical  importance, 
save  for  the  necessity  of  palliation  of  the  urinary  symptoms. 

MoEBiD  Anatomy. — The  morbid  anatomy  of  prostatic  tuberculosis  is 
essentially  the  same  as  that  of  other  organs  and  tissues  similarly  affected. 
The  characteristic  grayish  granulomatous  infiltration,  caseating  j'ellow  gran- 
uloma, cavities  formed  by  caseation  and  liquefaction,  diffuse  infiltration  and 
miliary  deposits,  cretaceous  degeneration,  fibrosclerotic  change,  and  cica- 
trization of  cavities  are  all  found  in  different  cases  at  different  stages  of 
the  disease.  It  is  a  noteworthy  fact  that  pronounced  lesions  are  most  likely 
to  be  found  in  primary  prostatic  tuberculosis,  or  in  that  secondary  to  dis- 
ease of  contiguous  and  correlated  organs.  Patients  with  prostatic  tuber- 
culosis secondary  to  pulmonary  or  other  serious  forms  of  tubercular  disease 
usually  die  from  the  general  affection  long  before  the  prostatic  tuberculo- 
sis has  had  time  to  develop  serious  lesions. 

A  greater  or  less  degree  of  enlargement  of  the  prostate  is  likely  to  be 
foimd  sooner  or  later  in  prostatic  tuberculosis.  Enlargement  appears  earlier 
where  the  periprostatic  lymphatics  and  glands  are  primarily  involved,  or 
in  cases  of  primary  interstitial  deposit,  than  in  cases  in  which  the  disease 
first  appears  as  a  tubercular  prostatitis  limited  primarily  to  the  mucous  and 
submucous  tissues  of  the  prostatic  urethra.  The  enlargement  may  be  dif- 
fuse or  limited  to  one  or  the  other  lobe.  Earely,  if  ever,  is  it  symmetrical. 
The  enlargement  is  due  to  two  factors,  viz.:  1.  A  deposit  of  tubercular 
elements.  2.  Consecutive  inflammation,  with  interstitial  proliferation  of 
young  connective  tissue.  The  ordinary  features  of  prostatic  tuberculosis 
may  at  any  time  be  modified  by  acute  inflammation  or  abscess  from  mixed 
infection  or  traumatism. 

In  primary  prostatic  tuberculosis  the  enlargement  is  likely  to  involve 


MOKEID   ANATOMY    OF    TUBEKCULOSIS    OF    THE    PEOSTATE.  677 

both  lobes^  although  unequally.  In  the  secondary  form  of  the  disease  one 
lobe  only  may  be  primarily  affected,  although  both  may  become  involved 
later  on.  In  eases  secondary  to  tuberculosis  of  the  testicle,  and  where  one 
testicle  only  is  enlarged  as  a  condition  secondary  to  a  deposit  in  the  prostate, 
only  one  lobe  is  likely  to  be  implicated,  at  least  primarily.  In  some  cases  in 
which  the  prostatic  disease  is  secondary  to  general  tuberculosis,  gray  granu- 
lomatous deposits  may  be  the  initial  process.  It  would  appear,  however, 
that  most  often  the  initial  deposit  consists  of  characteristic  yellowish  granu- 
lomatous nodules.  These  undergo  sooner  or  later  more  or  less  softening, 
perhaps  liquefaction,  forming  the  so-called  tubercular  abscess,  the  charac- 
ters of  which  may  closely  approximate  ordinary  abscess,  provided  secondary 
infection  with  pus-microbes  occurs.  The  caseating  nodules  or  yellowish 
granulomatous  nodules  may  remain  comparativelj^  quiescent  for  a  long 
time.  In  cases  in  which  secondary  mixed  infection  occurs  and  pus-mi- 
crobes play  the  most  important  role  the  process  may  assume  a  more  or  less 
acute  form,  and  an  erroneous  diagnosis  is  likely  to  be  made.  Primary  tuber- 
cular deposit  most  generally  occurs  about  the  acini  of  the  glands.  It  may, 
however,  first  invade  the  submucous  tissue  of  the  prostatic  urethra.  The 
deposit  soon  undergoes  caseation  and  invades  the  epithelium  of  the  pro- 
static urethra,  with  resulting  ulceration  and  perhaps  perforation.  This  con- 
stitutes the  so-called  tuberculo-ulcerative  prostatitis,  and  is  the  form  in 
which  a  positive  diagnosis  is  most  easily  made.  In  other  instances  a  caseat- 
ing cavity  at  some  distance  from  the  mucous  membrane  softens  and  burrows 
toward  the  free  surface,  finally  opening  into  the  urethra.  Abscess-cavities 
and  ulcers  of  the  prostatic  urethra  are  soon  followed  by  secondary  mixed 
infection  and  perhaps  by  infiltration  of  urine,  urinary  abscess,  and  fistula. 
These  lesions  present  no  tendency  to  cicatrization  and  spontaneous  cure. 
When  the  entire  gland  or  one  entire  lobe  is  involved,  the  process  may  ex- 
tend chiefly  toward  the  rectum.  Xodules  are  found  in  the  substance  of  the 
gland  perceptible  in  rectal  exploration.  These  may  soften,  with  or  without 
secondary  mixed  infection,  and  form  tubercular  abscesses  opening  into 
the  periprostatic  cellular  tissue— chronic  periprostatic  abscess.  This  may 
eventually  open  into  the  rectum.  The  pus  may  burrow  upward  and  later- 
ally, forming  large  tubercular  cavities  in  the  perirectal  tissues.  In  other 
instances  they  may  open  into  the  urethra,  after  which  ordinary  urinary 
abscess  forms.  Several  caseating  foci  may  coalesce,  forming  one  large  ir- 
regular cavity  with  rigid,  and  perhaps  eventually  calcareous,  walls.  Cal- 
careous transformation  or  fibrosclerotic  change  of  the  walls  of  the  cavities 
with  absorption  of  their  contents,  fibroid  degeneration,  and  contraction  of 
the  entire  mass  occur  exceptionally  and  result  in  a  spontaneous  cure.  In 
such  cases  the  condition  of  the  prostate  is  one  of  atrophy,  with  cicatricial 
contraction  and  partial  destruction  of  the'  normal  glandular  and  muscular 
tissues. 

In  extreme  cases  of  tubercular  abscess  the  entire  gland  is  represented 


678  TUBEECULOSIS    OF    THE    PEOSTATE. 

by  a  pus-sac.  This  may  or  may  not  invade  the  urethra.  When  it  does,  the 
urine  enters  the  cavity;  and  decomposition,  local  and  perhaps  general  septic 
infection,  and  a  more  or  less  acute  urinary  abscess  may  result.  The  sinuses 
that  form  as  a  result  of  tubercular  abscess  may  burrow  in  various  directions. 
They  most  often  open  upon  the  perineum  in  the  neighborhood  of  the  anus, 
their  next  most  frequent  direction  being  toward  the  rectum,  into  which 
they  finally  emerge.  They  have  been  known,  however,  to  open  in  the 
hypogastric  region  or  some  distance  away  upon  the  abdominal  walls  or 
thighs.  A  small  primary  focus  or  perhaps  several  small  foci  may  remain 
quiescent  in  the  prostate  for  many  years,  possibly  for  an  indefinite  period. 
This  explains  the  extremely  slow  progression  of  many  cases  in  which  a 
diagnosis  of  prostatic  tuberculosis  is  made,  admitting  that  at  least  a  fair 
proportion  of  such  diagnoses  are  correct.  The  rule  is,  however,  that  gen- 
eral infection  and  a  fatal  result  occur  sooner  or  later.  It  is  obvious  that  a 
fatal  result  occurs  much  earlier  where  the  prostatic  disease  is  secondary  to 
tuberculosis  of  other  and  more  important  organs. 

It  is  not  easy  to  determine  the  primary  seat  of  infection  in  prostatic 
tuberculosis.  It  is  often  a  perplexing  problem  to  decide  whether  the  pri- 
mary deposit  occurred  in  the  prostate  or  in  some  other  organ-  or  tissue. 
Even  when  secondary  to  tuberculosis  of  contiguous  and  correlated  organs 
and  tissues,  it  is  not  always  a  simple  matter  to  determine  the  precise  relation 
between  the  prostatic  and  contiguous  disease:  e.g.,  if  the  prostatic  tuber- 
culosis is  associated  with  a  similar  process  in  the  testicle,  it  is  not  always 
easy  to  determine  the  primary  seat  of  the  disease.  From  a  clinical  stand- 
point, it  is  probably  most  generally  believed  that  the  prostatic  disease  is 
secondary  to  that  of  the  epidid^anis.  In  many  cases,  however,  it  seems 
logical  to  infer  that  the  tubercular  infection  has  traveled  from  the  prostatic 
urethra  via  the  ejaculatory  duct  and  vas  deferens  to  the  epididymis.  This 
may  be  inferred  especially  when  the  symptoms  of  prostatic  disease  precede 
for  some  time  the  morbid  changes  in  the  testicle,  and  where  both  epididymes 
are  involved  at  about  the  same  time.  It  must  be  remembered,  however,  that 
small  tubercular  nodules  and  slight  infiltration  of  the  epididymis  may  exist 
for  a  long  time  prior  to  the  development  of  prostatic  symptoms  without 
attracting  the  patient's  attention,  the  first  objective  manifestation  of  dis- 
ease being  referred  to  the  urinary  function.  From  a  pathologic  stand- 
point, it  is  fair  to  infer  that  when  the  process  in  the  prostate  is  far  advanced 
and  that  of  the  testis  is  insignificant,  the  prostatic  tuberculosis  is  the  pri- 
mary condition.  This,  however,  is  not  to  be  accepted  without  qualification, 
inasmuch  as  the  process  in  the  testicle  is  always  slow,  often  innocuous,  and 
not  likely  in  a  large  proportion  of  cases  to  go  on  to  extensive  destruction 
unless  some  source  of  mixed  infection  occurs.  The  condition  of  the  sper- 
matic cord  is  apparent^  not  a  fair  criterion  from  which  to  decide  the  pri- 
mary or  secondary  relation  of  the  prostatic  to  the  testicular  disease.  It 
would  appear  that  infections  of  all  kinds  may  expend  their  violence  upon 


SYMPTOMS    AND    DIAGNOSIS    OF    PEOSTATIC    TUBEECULOSIS.  679 

what  may  be  termed  for  practical  purposes  the  two  extremities  of  the  semi- 
nal tube,  while  the  intervening  cord  remains  healthy.  Tubercular  adenitis 
and  lymphangitis  are  very  important  factors  in  prostatic  tuberculosis.  As 
Lannelongue  pointed  out,  the  lymphatic  glands  between  the  bladder,  pros- 
tate, and  rectum  may  be  the  initial  point.  In  such  cases  speedy  softening 
with  early  opening  into  the  rectum  may  occur.  In  some  cases  of  prostatic 
tuberculosis  there  is  general  genito-urinary  infection,  primary  or  secondary. 
The  kidneys,  bladder,  and  ureters  may  be  involved,  the  infection  traveling 
up  from  the  prostate  to  the  kidneys,  or  vice  versa.  Instead  of  this  gradual  ex- 
tension, upward  or  downward,  the  kidneys  may  be  the  primary  seat  of  tuber- 
cular deposit,  the  prostate  presenting  secondary  tuberculosis  from  bacillary 
infection,  either  by  the  urine  or  in  a  more  roundabout  way  via  the  general 
circulation. 

Symptoms  and  Diagnosis. — -When  the  prostatic  urethra  is  the  seat 
of  tubercular  deposit,  with  or  without  involvement  of  the  bladder,  the  symp- 
toms are  essentially  the  same  as  in  any  chronic  inflammation  of  this  part. 
Pain  referred  to  the  region  of  the  bladder,  perineum,  thighs,  groins,  urethra, 
testes,  and  rectum  may  be  complained  of  in  different  cases.  Frequent  and 
painful  micturition,  increasing  in  severity  as  the  vesical  neck  becomes  in- 
vaded, is  the  most  uniform  symptom.  Some  hematuria  is  sometimes  ob- 
served. This  is  not  profuse,  as  a  rule,  and  is  limited  to  the  last  few  drops  of 
urine.  Sometimes,  however,  it  is  moderately  free,  and  if  the  urethra  is  in- 
volved anterior  to  the  triangular  ligament  urethrorrhagia  may  occur.  The 
fusiform  clot  characteristic  of  prostatic  hemorrhage  is  sometimes  seen. 
Acute  retention  of  urine  may  occur  from  the  supervention  of  hyperemia, 
simple  inflammation,  spasm,  or  the  formation  of  a  mixed  abscess.  The  urine 
contains  muco-pus,  epithelium,  thready  filaments,  and  sometimes,  if  ulcera- 
tion exists,  particles  of  tuberculous  tissue.  Discharge  of  a  muco-purulent 
character  is  present  where  the  anterior  urethra  is  involved.  This  may  be 
constant  or  recurrent.  Bacilli  may  or  may  not  be  present;  they  are  rarely 
to  be  observed  unless  ulceration  or  abscess  exists.  In  general,  the  discharge 
is  that  of  a  stubborn  so-called  posterior  urethritis, — i.e.,  follicular  prostatitis, 
— and  creeps  back  into  the  bladder  or  is  intermittent,  occurring  only  during 
stool,  in  the  coup  de  piston,  or  on  digital  pressure  via  the  rectum.  When  the 
discharge  escapes  spontaneously  from  the  meatus  the  anterior  urethra  is  also 
involved,  not  necessarily  in  a  tubercular  urethritis,  but  sometimes  in  simple 
chronic  inflammation.  Sometimes  a  large  quantity  of  pus  suddenly  appears 
in  the  urine.    This  is  indicative  of  the  evacuation  of  an  abscess  pe?'  uretliram. 

When  the  tubercular  deposit  is  at  the  periphery  of  the  prostate  or  in 
the  periprostatic  tissue,  there  may  be  no  symptoms  for  a  long  time.  The 
patient  is  not  likely  to  complain  unless  the  bladder,  urethra,  or  testes  be- 
come involved.  There  may  be  some  pain  and  weight  in  the  perineum,  with 
tenderness  upon  pressure,  a  moderate  amount  of  rectal  tenesmus,  and  pain 
in  defecation;    but  these  symptoms  are  usually  noticeable  only  after  suffi- 


680  SYMPTOMS    AND    DIAGNOSIS    OF   PEOSTATIC    TTJBEECULOSIS. 

cient  tubercular  material  has  become  deposited  to  produce  more  or  less 
mechanic  disturbance. 

As  will  be  observed,  there  is  nothing  pathognomonic  about  the  fore- 
going symptomatology.  The  most  definite  symptoms  are  objective,  and 
determinable  only  by  rectal  exploration.  The  prostate  is  found  to  be  the 
seat  of  an  irregular  nodular  enlargement  with  perhaps  areas  of  softening. 
A  granular  feel  of  the  periprostatic  tissue  has  been  described.  The  seminal 
vesicles  are  sooner  or  later  involved,  as  a  rule,  and  are  thickened,  nodular, 
and  tender.  Distinct  abscess  may  be  found.  After  evacuation  of  the  tuber- 
cular abscess  relative  atrophy  and  perhaps  sclerosis  of  the  prostate  are  ob- 
served. Catheterization  may  result  in  the  detection  of  the  abscess-cavity, 
which  is  usually  situated  upon  the  floor  of  the  prostatic  urethra. 

It  is  obvious  that  it  is  quite  easy  to  make  diagnostic  errors  where  there 
is  no  softening  or  ulceration  of  the  prostate.  The  presence  of  bacilli  in 
the  urine  or  urethral  discharge  constitutes  the  only  positive  sign  of  tuber- 
culosis. Since  so  much  has  been  written  upon  tuberculosis  of  the  genito- 
urinary tract  many  mistakes  in  diagnosis  have  been  made.  With  some  sur- 
geons, more  or  less  hardness  of  one  or  the  other  epididymis  and  a  little 
enlargement,  tenderness,  and  nodulation  of  the  prostate  are  sufficient  to 
warrant  a  diagnosis  of  prostatic  tuberculosis.  It  must  be  remembered,  how- 
ever, that  simple  chronic  inflammation  of  the  epididymis  may  present  the 
same  signs,  so  far  as  the  testes  are  concerned.  Simple  adenitis  or  peripro- 
static adenitis  with  chronic  follicular  prostatitis  may  afford  all  of  the  other 
signs  upon  which  the  diagnosis  of  tubercular  disease  of  the  prostate  is  fre- 
quently based.  In  the  experience  of  the  author,  it  is  not  unusual  to  meet 
with  such  cases  that  have  been  pronounced  tuberculosis  of  the  prostate. 
Under  the  ordinary  measures  of  treatment  of  follicular  prostatitis  many  of 
these  cases  readily  yield.  The  inference  is  obvious:  either  many  cases  of 
tuberculosis  of  the  prostate  are  mild,  comparatively  harmless,  and  readily 
amenable  to  treatment,  or  else  frequent  mistakes  in  diagnosis  occur.  The 
latter  is  the  author's  inference. 

When  a  sluggish,  slow  developing,  comparatively  painless  and  insen- 
sitive enlargement  of  one  or  both  epididymes  exists,  with  symptoms  of 
chronic  prostatic  inflammation,  and  nodular  enlargement  of  the  prostate 
determined  by  rectal  examination,  a  diagnosis  of  probable  prostatic  tuber- 
culosis is  warrantable.  The  detection  of  bacilli  in  the  urine  or  discharge, 
or  the  formation  of  characteristic  tubercular  abscesses  and  sinuses  are  neces- 
sary, as  a  rule,  for  a  positive  diagnosis.  In  a  case  presenting  the  prostatic 
s3'mptoms  just  described  and  at  the  same  time  evidences  of  tuberculosis  of 
the  lungs,  peritoneum,  bones,  or  general  lymphatic  system,  the  inference 
regarding  the  prostatic  disease  is  obvious.  The  heredity  of  the  patient  and 
his  general  condition  are  important  factors  in  the  diagnosis.  Koch's  tuber- 
culin affords  a  diagnostic  test. 

There  is  no  regularity  in  the  course  of  the  disease.     Some  patients  suf- 


CANCEE    OF    THE    PEOSTATE.  681 

fer  acutely  at  an  early  period,  where  the  urethra  and  bladder  are  involved. 
Others,  especially  when  the  urethra  is  not  primarily  or  early  invaded,  may 
tolerate  the  condition  for  a  very  long  time.  Complete  arrest  of  the  disease 
and  spontaneous  cure  may  result,  as  shown  in  the  description  of  its  morbid 
anatomy. 

Teeatment. — In  prostatic  tuberculosis  secondary  to  disease  of  other 
important  organs,  the  treatment  is  that  of  the  primary  disease,  excepting 
in  so  far  as  local  measures  of  palliation  may  be  instituted.  Where  it  is 
primary,  or  secondary  to  tuberculosis  of  contiguous  organs,  the  treatment 
of  the  local  difficulty  assumes  a  more  prominent  position.  General  treat- 
ment should  be  based  upon  the  same  principles  as  in  tuberculosis  elsewhere, 
due  consideration  being  given  to  tonic  and  alterative  treatment,  nutrition, 
and  change  of  climate.  The  method  of  hypodermic  medication  by  iodin 
and  ehlorid  of  gold  in  the  form  of  Clark's  solution  offers  some  hope  of 
benefit  or  even  cure.    The  same  may  be  said  of  nucleins  and  tuberculin. 

The  local  treatment  should  consist  first  of  irrigation  of  the  bladder 
and  prostate  with  warm  solutions  of  boric  acid,  followed  by  the  instilla- 
tion of  iodoform-and-ether  emulsion.  Iodoform  in  the  form  of  rectal  sup- 
positories has  seemed  beneficial.  Instillations  of  silver  nitrate  and  other 
irritant  astringent  drugs  are  rarely  beneficial,  and  are  most  likely  to  prove 
injurious;  it  has  even  been  asserted  that  such  treatment  may  precipitate 
ulceration.  Where  possible,  it  is  best  to  irrigate  the  bladder  and  prostate 
by  means  of  a  short  urethral  nozzle  rather  than  by  instruments  necessitating 
more  or  less  mechanic  irritation  of  the  prostate.  Although  not  universally 
accepted,  the  author  is  convinced  that  putting  the  bladder  at  rest  and  pro- 
viding through-and-through  drainage  at  an  early  period  of  the  disease  is 
likely  to  prove  curative  in  quite  a  proportion  of  cases.  When  abscesses 
form,  they  should  be  evacuated,  scraped,  and  packed  with  iodoform  gauze; 
all  sinuses  should  be  thoroughly  curetted  and  treated  with  iodoform.  In- 
terstitial injections  of  iodoform  emulsion  into  the  affected  gland  constitute 
a  logical  method  of  treatment.  Cases  are  reported  where  large  tubercular 
abscesses  of  the  prostate  have  been  opened,  curetted,  and  drained,  with  re- 
sulting cure;  but  in  marked  cases  of  prostatic  tuberculosis  recovery  is  rare. 
Sooner  or  later,  the  bladder,  kidneys,  or  distant  organs  become  secondarily 
affected.  When  prostatic  tuberculosis  is  secondary  to  tubercular  disease  in 
other  important  organs  the  death  of  the  patient  is  inevitable. 

CANCEE   OF    THE    PEOSTATE. 

Malignant  disease  of  the  prostate  is  rare,  yet  it  is  probably  more  fre- 
quent than  ordinarily  supposed,  being  often  erroneously  diagnosed.  His- 
tologically, malignant  disease  of  the  prostate  occurs  in  two  forms,  viz. :  sar- 
coma and  carcinoma.  It  is  found  at  the  two  extremes  of  life,  being  excep- 
tional between  the  ages  of  ten  and  fifty  years.  It  is  occasionally  found  in 
very  young  children.    In  something  over  85  per  cent,  of  cases  the  malig- 


683  SYMPTOMS  or  cancer  of  the  peostate. 

nant  affection  assumes  the  form  of  carcinoma,  the  remainder  being  of  a 
sarcomatous  character.  Sarcoma  is  the  form  that  is  most  likely  to  be  met 
with  in  young  patients. 

Cancer  of  the  prostate  occurs  clinically  in  three  forms,  viz.:  (1)  pri- 
mary; (2)  as  an  infection  secondary  to  malignant  disease  of  contiguous 
organs;  (3)  by  infection  via  the  blood.  The  form  most  often  seen  is  sec- 
ondary to  malignant  disease  of  the  penis,  testes,  bladder,  or  kidneys.  As 
Guyon  has  shown,  primary  prostatic  cancer  has  but  little  tendency  to  in- 
vade the  bladder,  but  speedily  involves  the  lymphatics,  especially  of  the 
pelvis.  This  latter  clinical  fact  suggested  to  Guyon  the  term  prostato- 
pelvic  cancer.  The  disease  may  be  at  first  circumscribed.  It  is  usually, 
however,  diffuse.  The  capsule  of  the  gland  may  alone  be  affected,  at  least 
primarily.  Eventually  extensive  pelvic  invasion  occurs,  with  involvement 
of  the  seminal  vesicles,  base  of  the  bladder  and  sometimes  its  mucous  mem- 
brane, the  rectum,  and  urethra.  Mixed  infection  and  suppuration  may 
eventually  develop. 

The  following  case,  although  open  to  impeachment  as  regards  post- 
mortem study,  is,  in  the  author's  opinion,  an  illustration  of  primary  cancer 
of  the  prostate  secondarily  involving  the  bladder. 

Case. — W.  H.,  aged,  43,  merchant,  suffered  from  painful  micturition,  and 
hematuria  coming  on  at  the  end  of  the  act  of  micturition.  The  pain  accompanying 
this  part  of  the  function  was  excniciating.  The  family  history  was  excellent. 
He  had  never  had  any  illness  of  any  kind,  and  was  absolutely  free  from  lumbar 
pain,  or  any  indications  of  disease  of  the  kidney  so  far  as  subjective  symptoms  were 
concerned.  His  habits  had  always  been  good.  During  the  war,  in  which  he  was  a 
soldier,  he  had  a  slight  attack  of  ague,  and  had  never  been  under  the  doctor's  care 
since  until  the  jDresent  trouble  began.  About  six  months  or  more  before  consult- 
ing the  author  the  patient  developed  pain  in  the  penis  and  testes,  gradually  increas- 
ing in  severity,  until  finally,  in  conjunction  with  frequent  and  painful  micturition, 
he  was  kept  awake  at  night.  His  urine  had  been  normal,  and  had  been  carefully 
examined  many  times  during  the  course  of  his  trouble.  Shortly  before  consulting  the 
author,  however,  his  hematuria  began.  He  had  been  examined  several  times  for 
stone  in  the  bladder.  He  experienced  frequent  desire  to  defecate,  though  having  but 
one  movement  daily.  Examination  showed  the  prostate  to  be  enlarged  and  somewhat 
tumefied,  with  some  suspiciously  resistant  points  here  and  there.  Cystoscopy  was  not 
feasible  because  of  extreme  vesical  irritability.  Despite  the  fact  that  there  was  no 
history  of  venereal  trouble,  and  because  of  the  age  of  the  subject,  the  case  was  con- 
sidered as  one  of  chronic  prostatitis,  although  a  slight  suspicion  of  malignancy  was 
entertained.  This  patient  was  afterward  lost  sight  of,  but  the  ease  finally  went  on  to 
a  fatal  result,  and  the  author  was  informed  by  the  attending  physician  that  cancer  of 
the  bladder  was  found  upon  autopsy.  As  a  report  of  the  condition  of  the  other  organs 
was  not  given,  there  are  no  means  of  proving  the  primary  nature  of  the  prostatic 
disease.  This  case  is  a  very  striking  one,  as  suggestive  of  the  caution  necessary  in 
the  diagnosis  and  the  prognosis  of  cases  with  similar  symptoms,  on  account  of  the  age 
of  the  patient  and  the  absence  of  symptoms  elsewhere. 

Symptoms. — Frequent  and  painful  micturition  with  hematuria — and, 
if  ulceration  of  the  prostate  exists,  more  or  less  purulent  discharge — con- 


CALCULUS    OF    THE    PEOSTATE.  683 

stitute  the  main  sj'mptomatic  features.  Pain  is  likely  to  be  most  severe  at 
night,  and  is  often  referred  to  the  region  of  the  rectum.  As  the  pelvic 
tissues  become  extensively  involved,  pressure  irritation  and  resulting  pain 
in  one  or  both  sciatic  nerves  is  likely  to  develop.  Intrapelvic  pressure  also 
may  produce  more  or  less  obstruction  of  the  iliac  veins,  with  resultant 
edema  of  the  limbs.  Constipation  from  mechanic  pressure  upon  the  rectum 
may  be  observed.  Marked  cachexia  comes  on  at  a  comparatively  early 
period.    A  fatal  result  is  inevitable. 

Diagnosis. — In  the  differential  diagnosis  tuberculosis  and  prostatic 
hypertrophy  only  are  worthy  of  consideration.  A  hard,  nodular  enlarge- 
ment of  the  prostate  with  cachexia,  pronounced  symptoms  referable  to  the 
vesical  neck,  and  extreme  pain  suggestive  of  pelvic  involvement,  taken  in 
connection  with  enlargement  of  the  pelvic  lymphatic  glands  and  those  of 
Scarpa's  triangle,  warrant  a  diagnosis  of  cancer.  When  cancer  exists  else- 
where in  the  body,  and  especially  if  it  has  invaded  organs  contiguous  to 
or  correlated  with  the  prostate,  the  diagnosis  is  a  very  simple  matter. 

Teeatmext. — Treatment  must  necessarily  be  palliative.  All  radical 
attempts  at  surgical  relief  have  thus  far  failed  of  their  object.  The  author 
believes  that  early  suprapubic  section  and  the  establishment  of  a  permanent 
artificial  urethra  is  the  principal  surgical  indication.  Great  relief  of  some 
of  the  most  annoying  symptoms  of  the  disease  and  prolongation  of  life 
are  likely  to  result  from  the  rest  and  relief  from  mechanic  irritation  thus 
secured. 

CALCULUS  OF  THE  PEOSTATE. 

Prostatic  concretions  or  calculi  are  sometimes  seen.  These  occur  in 
four  forms:  1.  A  variety  due  to  inspissation  of  the  secretion  of  the  pro- 
static follicles,  in  combination  with  the  deposition  of  earthy  salts.  These 
comprise  the  so-called  corpora  amylacea,  first  described  by  Morgagni  in  1723. 
2.  Small  calculi  of  urinary  formation,  which  have  formed  in  the  kidneys 
or  bladder  and  have  become  lodged  in  the  prostatic  urethra.  3.  Calculi  due 
to  the  deposition  of  urinary  salts  and  mucus  in  some  pathologic  crypt  or 
behind  some  obstruction  of  pathologic  formation  in  the  prostatic  urethra. 
4.  Phleboliths. 

Concretions  of  the  first  variety  are  found  in  the  prostate  on  post-mor- 
tem in  cases  in  which  there  have  been  no  symptoms  referable  to  the  organ 
during  life.  Minute  concretions  of  this  kind  are  sometimes  found  in  the 
urine.  They  are  at  first  of  microscopic  size,  and  in  the  majority  of  cases 
never  attain  sufficient  dimensions  to  be  of  any  practical  importance.  As 
seen  with  the  microscope,  they  are  small,  ovoid  bodies  of  a  light^yellow 
tint  and  pearly  luster.  In  the  large  concretions  the  color  is  a  dark  orange. 
When  first  formed  they  are  soft,  but  later  on  they  become  calcified  and 
hard.  They  are  somewhat  similar  to  the  concretions  that  form  in  the  fol- 
licles of  the  tonsil  and  are  occasionally  coughed  up  by  patients  with  chronic 


684 


CALcrrrs  of  the  peostate. 


lancial  disease.  In  elderly  patients  they  may  attain  tlie  size  of  a  pea  or 
larger,  and  may  be  Tery  abundant.  Tbompson  describes  a  ease  iq  wbicb 
seTeral  tbonsand  of  these  concretions  were  visible  microscopically.  Tbey 
are  fonnd  in  the  secreting  follicles  and  excretory  ducts,  constituting  tbe 
parenchyma  of  the  prostate.  The  earthy  material  is  deposited  very  slowly 
in  concentric  laminae,  as  is  the  case  with  phosphatic  vesical  calculi.  The 
walls  of  several  ducts  and  follicles  may  be  absorbed  and  form  a  single  cav- 
ity within  which  a  number  of  such  concretions  may  be  found.  When  they 
become  larger  and  the  opening  of  the  cavity  containing  them  communicates 
freely  with  the  prostatic  urethra,  the  salts  of  the  urine  are  deposited  about 
them,  and  they  become  genuine  prostatic  calculi.  Cases  have  been  reported 
in  which  the  entire  prostate  was  converted  by  absorption  into  a  sac  com- 


JPro  state 

Fior.   130. — Prostato-vesical  ealeulus. 


(After  Bryant.) 


pletely  distended  with  small  calculi  that  could  be  felt  rolling  under  the 
fingers  lite  beans  in  a  bag.  Prostatic  calculi  sometimes  fuse  together  and 
form  a  sort  of  cast  of  the  prostatic  ducts  and  urethra.  A  length  of  four  or 
five  inches  has  been  said  to  have  been  attained.  Thompson  refers  to  a  case 
in  which  there  were  nine  fragments  weighing  alt-ogether  3  ^/^  ounces. 
Chemically,  true  prostatic  calctili  are  composed  chiefly  of  calcic  phosphate 
and  a  email  quantity  of  ammonio-magnesian  phosphate.  They  never  give 
rise  to  trouble  unless  they  are  exceptionally  large,  in  which  event  they  occa- 
sion a  certain  amount  of  mechanic  disturbance  and  urinary  obstruction. 
Small  prostatic  calculi  should  not  be  disturbed  even  where  their  existence 
is  recognized  unless  they  give  rise  to  definite  symptoms.  Should  they  do 
so,  they  may  be  removed  by  perineal  section.     In  rare  instances  they  may 


CALCULUS    OF   THE    PEOSTATE.  685 

cause  ulceration  and  abscess,  and  finally  be  discharged  into  the  urethra, 
bladder,  perineum,  or  rectum. 

Prostatic  concretions  are  quite  generally  believed  to  be  characteristic 
of  senility;  the  author  has  however  found  them  to  be  not  infrequent  in 
yoimg  subjects.  Eastman  has  had  a  similar  experience,^  finding  them  in 
very  yoimg  subjects,  and  in  twenty-two  out  of  twenty-four  prostates  ex- 
amined. Eastman  holds  for  the  amyloid  character  of  the  corpora  amylacea 
and  claims  that  they  are  largely  of  epithelial  origin.  He  apparently  shows 
that  the  laminated  formation  of  these  bodies  is  due  to  their  origin  in  con- 
centric rings  of  epithelium. 

Calculi  are  often  found  in  the  tissues  about  the  prostate  and  neck  of 
the  bladder  at  some  distance  from  the  prostate  proper.  The  author  has 
found  them  several  inches  above  the  vesical  neck. 


^  "The  Origin  of  Corpora  Amylacea  in  the  Prostate  Gland."  Joseph  E.  Eastman, 
B.Sc,  M.D.  Journal  of  the  American  Medical  Association,  July  24,  1897.  This  is  a 
valuable  trocTiure,  and  worthy  of  more-extended  mention  than  can  be  accorded  it  here. 


z<ms 


^tiMmMB«<«  mse 


1-  1     :  i-rn^a5'ta3£  '^ast  wbmMIp  9^  site  ^ibjeet;  to  it,  sad.  aie 

1  '  ";  ^y&  Wt  t^n^  JMnwMlg  Off  wngWT'  gp««n»l  pntdl- 

-QCBdeasdaoid  ihf  dSsease  and,  aM»\e  e^edallj. 


iifti<ti!j^ll  thn  imnKisr 


-»erT  i-pw 


c-  ecmd:" 


.€  sisbfeetof 


■  rsmT-felT  liie  eanse  oi  ike 


T  zii  TieTri.- 


g1  io^ie  331 


te  litkE  .stfflaciT^2natp--ecviff  smfflucm  oi  ttke  T^ems  an.  Teiatiom  to  ti-  -  - . : : 
wMff  " : ' "  "•; : '  " : '       t:   ^  r     f  th^se  T'^eeOs.    T!im--":r  - 

gsstar^     -     -  -   ■       T  '                       nip-Vi  liTrng  or  anT  c"-  -:          .   .  ._   - 

iBEBeaiet  tfiap  eaugo  Mrtcm  311  lios  aregSggi.    Home  Ijebered  tJaat  traii- 

^^  "thai-  prrodiiBefl  1?t  lacasebaek-aifliiig — sen  '     t  '     t- 
«fe^er  pKTS  01  lihe  prcsiacte  imptsie  -of  "felood-xet- 

lerar  Iw^jerErapirr.    Uns  nifntiiTe  ©f  v^sete  Ibe  liidieT^  to  •  -  ;i;  - 

lisffiiflfnaify  is&  tiS^  »iTHtfgffiP  taa  #)£•  -pert  of  Jiigh  Mwers  as  <e: :  J  -  -: 

BcsBS  tkIb®  Mr€  aJw^ywggp  said  tteaaapeaaJie  Et^e. 

Sr  CSarifes  B(dE  fflBerteS  liie -es^fieBee  r^  ;   ::-■'--:.  .-T^r  to  prostatic 
last  <€a(3  sk^i  ^Sss&  ickv^  ^recBsj'o-,:  _r_.     .-_  ;i:__7TJig  tQcli  pre- 
-eamses  1®  be  affisoeiaxed  Trat3i  irritarioii 
of  ^ie  M^SSes;.  wii^  jggnMiBg  fs^qoseiat  eoiBtiafftiiiMas  'of  liist  TiseTi£.    As  a 


consequence  of  tKese  contcaetions  of  the  "bladder.  Ke  "belieTed.  tJifi:  inrediral 
mnscles  to  be  tiie  seat  of  oreiaetion,  resulting  in  a  dntwing  back  of  ihe  *;- 
called  median  lobe  so  as  to  eleTate  it.  th-ns  causing  xainarr  Qbstztietian, 

Sanmel  Cooper  confessed  ign.orance  of  tKe  causes  of  proaiatic:  Kypec- 
tropby.  He  seemed  to  tbfnir  from  hiz  experienee.  hewe^eE,  tiiat:  people  wba 
led  sedentary  Hres  were  most  liable  to  the  affeetLon. 

Astlej  Cooper  arbitrarily  stated  that  bypercropKy  of  tbe  prostate  wii 
tbe  consequence  of  old  age  alon&.  and  not  of  disease.  Brodie  also  bettered 
tbat  enlarg'ed  prostate  was  a  matter  of  eotose  in  old  m.en-  He  iield  thjsk. 
prostatie  iiypertropliy  neTer  bec-omes  manifest  utttI  tbe  deTelopment  of 
plainly-marked  eyidenees  of  senility. 

Tb.e  late  Dr.  G-ross  erpre^ed  tfie  Tiew  that  prostatie  h-ypernropty  mfght 
result  from  habitual  engorgement  o£  the  organ,  incidenxal  to  protraeted  and 
repeated  sexual  interc-ourse.  irritation  from  Tesical  calctiius.  the  free  ttse 
of  srimnlating  dinretLes  and  aLeokoEc  or  msik  iiqnora.  espesure  to  eold,  tiie 
suppression  of  ctitaneotis  diseases,  gotct  and  iltetmiatEm,  tramnatism,  fre- 
quent cath.eterization-  and  habitual  straining  at  stooL  as  in  ebrQuie  dfar- 
rtea  and  other  affections  of  the  bowels. 

Mercier  classed  as  predisposing  causes  ail  conditiciii  i^i  —  ~~r~:i5s 
faToring  circulatory  sluggishness.  Acc-ording  to  brmj  rr^izZi.  it  'srzzsizjirL^ 
habit  with  plenty  of  eeHuIar  and  adipose  tissue  hare  ggngEaHy  &  lax  sid 
unresisting  Tenous  system.  Such  subjects,  he  daime^  are  m:  -~  ±r  .~tz:'_- 
the  TLCtims  of  prostatic  enlargement.  He  considered  that  5e---.i".:~  --i.is 
favored  the  disease. 

Amussat  stated  that  syphilis,  a  f  oreigiL  body  in  trie  gIj,  i  ir z .  m  i  ^tti  ;~ize 
of  the  urethra  were  the  most  c-omm-on  causes  of  prostatic  rzl^zgrziriii.  B: 
is  observed,  he  claimed.  cMefly  in  elderly  persons  who  have  for  a  Ling  ~-- 
used  sounds  or  bougies  upon  themselves. 

Desault  claimed  that  enlarged  prostate  was  ver^  icmnoit  ia  ddslj 
men,  and  those  who  have  had  miEiEterQUs  attacks  of  gen :  rrbri  He  believed, 
also,  that  the  disease  might  b-^i?  i  :i-"i'  i^'inn  i  5:7:^1^1  mi  :111a: 
cachexias- 

Civiale  placed  vesical  ealcnte  fiist  in  the  ©rdsr  ©f  efci : .  ;i  i  i  r  mm  in  le. 
He  considered  organic  stricture  of  the  urethra  seeini  "nl~  i"  --;  -_--'_- 
cuius.  He  denied  the  relation  of  veaereal  excesses  ti  iiii::zii  tniiiii:  iii- 
ease. 

Coulson  c-ontents  himself  wirh  the  presentatioiL  of  the  views  q£  others 
and  has  no  deiinite  opinion,  of  his  own. 

Thompson  expresses  imequivocally  his  belief  that  ptEostatic  enlarse- 
ment  is  seen  in  relatively  young  patients  as  a  result  of  fTrterM'it.rjTT  plastie 
elrusion.  due  to  fnffamTnation.  the  enlargement  occurring  in  old  age  being 
an  unnatural  development  of  the  prostatic  tistie  proper — Ia^  true  hyper- 
trophy. Acc-ording  to  him.  inflammatioiL  and  its  prodEciis  do  not  ntvor 
growrh.  but  are  directly  antagonisric  to  such  a  process.     A  inrostate  en- 


688  HTPEETKOPHT    OF    THE    PEOSTATE. 

larged  by  inflammatory  effusion  is,  therefore,  according  to  Thompson,  prob- 
ably less  likely  subsequently  to  become  hypertrophied.  jSTutrition  is  im- 
peded, not  encouraged.  In  brief,  Thompson  excludes  inflammation  from 
the  etiology.  Urethral  stricture  and  calculus  are  not  considered  by  him  to 
be  important  etiologic  factors.  He  does  not  believe  that  habitual  engorge- 
ment of  the  prostatic  and  hemorrhoidal  plexuses  has  much  to  do  with  the 
etiology  of  the  disease.    He  says: — 

True  hypertrophy,  in  any  situation,  never  has  venous  congestion  for  a 
cause;  venous  congestion  impairs  structure,  and  predisposes  to  ulceration  of 
the  tissues  affected  hy  it,  hut  it  neve?-  augments  vital  force  or  stimulates  growth. 

Upon  this  ground  Thompson  denies  congestion  as  a  possible  cause  of 
hypertrophy  of  the  prostate.  He  further  disputes  the  possibility  of  rheu- 
matism, gout,  or  syphilis  playing  any  part  in  the  pathologic  process.  As  to 
the  effect  of  sexual  excesses,  he  says: — 

Much  influence  has  been  attributed,  to  the  effect  of  habitual  indulgence  of  this 
kind;  but,  from  the  fact  that  the  affection  has  been  observed  to  occur  in  individuals 
known  to  have  been  remarkable  for  chastity,  the  opposite  extreme  of  continence  has 
been  regarded  as  exercising  a  similar  influence.  In  regard  to  the  first,  it  appears 
reasonable  to  believe  that  repeated  use  might  induce  hypertrophy  here  as  elsewhere; 
while,  without  entering  upon  the  question  of  the  prostatic  function,  it  is  impossible 
not  to  associate  the  organ  with  the  sexual  act,  and,  admitting  this,  it  is  not  easy 
to  escape  the  inference  that  hypertrophy  is  likely  to  result  from  sexual  excess;  yet 
facts  do  not  favor  this  view.  Hypertrophy  does  not  exist  when  the  function  is 
in  greatest  vigor  and  is  not  called  into  immediate  existence  by  the  most  licentious 
excesses  indulged  in  during  the  prime  of  life,  and  it  must  be  admitted  that  in  any 
part  of  the  body  hypertrophy  develops  itself  coincident  with  or,  at  all  events, 
immediately  follows  the   increased  action  which  induces  it. 

Although  Thompson  disputes  the  view  that  the  prostate  is  truly  a  se- 
creting gland,  he  admits  it  for  the  sake  of  argument,  and  claims  that  no 
other  gland  offers  a  pathologic  parallelism  with  hypertrophy  of  the  pros- 
tate, all  of  its  component  tissues  not  being  increased  in  their  normal  rela- 
tive proportions.  An  enlargement  of  the  gland  may  be  due  to  increase  of 
glandular  elements;  or,  on  the  other  hand,  to  a  change  in  structure  and 
increase  in  bulk  of  the  "prostatic  tissue  proper."  Thompson  does  not 
believe,  furthermore,  that  enlargement  of  the  prostate  is  a  simple  muscular 
hypertrophy  induced  by  increased  action.  He  calls  attention  to  the  close 
similarity  between  the  uterus  and  the  prostate  and  seems  to  think  that: — 

Just  as  during  the  latter  part  of  the  period  of  reproductive  activity  the  uterus 
is  prone  to  develop  new  growths  identic  in  structure  with  its  own,  a  similar  tend- 
ency will  be  found  to  develop  new  growths  in  the  prostate  at  a  corresponding  period 
in  life  of  the  male. 

Thompson's  tables  apparently  support  this,  by  showing  that  hyper- 
trophy of  the  prostate  is  a  disease  incident  to  old  age,  but  fails  to  indicate 
the  precise  connection  between  advancing  age  and  prostatic  hypertrophy. 


ETIOLOGY    OF   HYPEETKO]?HY    OF    THE    PEOSTATE.  689 

Even  granting  that  old  age  is  tlie  chief  etiologic  factor,  there  is  yet  much  to 
be  accounted  for.  Why  should  so  large  a  proportion  of  elderly  men  present 
a  condition  so  distinctly  pathologic,  affecting  an  organ  which,  in  old  age  at 
least,  should  be  practically  of  no  importance  from  a  physiologic  or  functional 
stand-point?  Thompson  himself  admits  that  prostatic  hypertrophy  is  not 
necessarily  or  even  usually  present  in  old  age,  but  is  rather  exceptional. 
According  to  him,  a  slight  tendency  to  hypertrophy  undetermined  during 
life  may  exist  in  about  one  in  three  individuals  after  60  years,  and  that 
marked  enlargement  may  affect  one  in  seven  or  eight  after  that  age.  Among 
40  prostates  of  elderly  men  dissected  by  Thompson  only  32  per  cent,  were 
appreciably  enlarged,  and  but  2  per  cent,  sufficiently  to  have  produced  symp- 
toms during  life.  Considering  the  function  and  period  of  greatest  func- 
tional activity  of  the  organ,  atrophy,  rather  than  hypertrophy,  should  be 
expected  in  old  age. 

The  modern  French  school,  following  the  distinguished  Guyon,  enter- 
tains the  peculiar  view  that  prostatic  enlargement  is  not  a  local  disease  and 
due  to  local  causes,  but  that  all  the  urinary  organs,  particularly  the  blad- 
der, undergo  analogous  changes,  the  origin  of  which  should  be  looked  for 
in  structures  bearing  absolutely  no  anatomic  relation  to  the  urinary  system, 
implying,  in  short,  that  enlargement  of  the  prostate  is  dependent  upon  gen- 
eral atheroma.  Thus,  this  school  claims  that  the  walls  of  the  bladder  be- 
come weakened,  with  resulting  accumulation  of  residual  urine,  followed 
by  cystitis,  prior  to  the  enlargement  of  the  prostate.  Eeginald  Harrison 
also  asserts  that  the  habit  of  partial  retention  frequently  precedes  the  ves- 
ical signs  of  prostatic  enlargement,  the  depression  of  the  posterior  wall  of 
the  bladder  being  a  primary  change.  In  this  the  author  heartily  concurs. 
Harrison  further  holds  that  depression  of  the  posterior  wall  of  the  blad- 
der results  in  compensatory  hypertrophy,  which  determines  the  develop- 
ment of  a  strong  muscular  band  or  buttress  at  the  base  of  the  trigone,  and 
finally  enlargement  of  the  prostate  itself. 

Even  though  we  admit  that  in  certain  cases  depression  of  the  floor  of 
the  bladder  and  alteration  in  the  walls  of  the  viscus  precede  perceptible 
pathologic  change  in  the  prostate,  it  is  obvious  that  this  condition  may  in 
no  way  be  causative  of  the  prostatic  disease.  Such  cases  are  no  argument 
against  what  appears  to  be  the  correct  view,  viz.:  that  serious  pouching  of 
the  bladder  is  generally  a  secondary  condition.  General  atheroma,  for  ex- 
ample, with  resulting  alteration  of  the  structure  and  power  of  the  bladder, 
might  occur,  and  subsequently  become  associated  with  hypertrophy  of  the 
prostate,  the  latter  condition  being  due  to  the  same  causes  as  in  other  cases 
in  which  prostatic  hypertrophy  is  unassociated — primarily  at  least — with 
disease  of  the  bladder. 

Much  of  the  etiologic  obscurity  of  prostatic  hypertrophy  is  probably 
due  to  the  clinical  fact  that  the  primary  condition  that  precedes  true 
hypertrophy  is  rather  exceptionally  brought  to  the  attention  of  the  surgeon. 


690  HYPEETEOPHY   OF    THE    PEOSTATE. 

A  certain  amount  of  diffuse  hyperplasia  from  prolonged  hyperemia  inci- 
dental to  various  causes  of  irritation  probably  exists  in  many  men  under 
middle  age.  It  is  not,  however,  until  distinct  hypertrophy  or  hyperplasia 
has  occurred  that  definite  symptoms  are  complained  of.  In  fatal  cases  the 
process  is  so  far  advanced  as  to  bear  very  little  resemblance  to  the  chronic 
engorgement  and  simple  hyperplasia  that  constituted  the  inital  stage  in  the 
so-called  hypertrophic  process.  As  for  Thompson's  views  regarding  the 
etiologic  importance  of  inflammation  and  circulatory  disturbance,  this  much 
may  be  said:  Chronic  congestion  and  inflammation  do  not  produce  genuine 
hypertrophy,  it  is  true,  but  they  do  cause  hyperplasia,  especially  where  the 
circulation  is  impeded  by  the  relatively  dependent  position  of  the  part. 
The  hyperactivity  of  the  organ  induced  by  the  resulting  irritation  will  ex- 
plain the  true  hypertrophic  element  of  the  disease,  which  is  really  subor- 
dinate to  the  hyperplasia.  This  argument  is  especially  applicable  to  the 
prostate,  which  is  a  glandulo-muscular  organ. 

Eacial  peculiarities  seem  to  have  a  marked  influence  in  the  etiology  of 
hypertrophy  of  the  prostate.  It  is  rarely  met  with  in  the  negro.  Our  dis- 
tinguished countryman,  Dr.  Hunter  McGuire,  states  that  he  has  never  met 
with  an  example  of  it  in  the  pure-blooded  negro,  but  has  seen  several  cases 
in  mulattoes.  Other  surgeons  claim  to  have  met  with  the  disease  in  pure- 
bloods. 

The  causes  of  the  disease,  according  to  the  views  of  the  author,  may  be 
classified  as  follows: — 

r  Senility. 
General  causes  J  The  gouty  or  rheumatic  diathesis. 
[  General  atheroma. 

r  Chronic  irritation  and  hyperemia  due  to  urethral  or  blad- 
der disease.    Early  prostatic  infection. 
Local  causes   ^    Masturbation.  ^ 

Sexual  excesses.  V  Eemote. 

1    Prolonged  and  ungratified  sexual  excitement.  J 

It  is  obvious  that  both  the  local  and  general  etiologic  factors  are  most 
effective  when  associated.  These  causes  are  not  all  recognized  by  most 
modern  authorities,  yet  would  appear  to  be  based  upon  sound  physiologic 
reasoning,  taking  into  consideration  the  structure  and  function  of  the  organ. 
The  prostate  is  one  of  the  most  important  of  the  sexual  organs.  It  is  par- 
ticularly important  because  it  is  the  seat  of  sexual  sensibility  and  involved 
in  the  venereal  orgasm.  One  of  the  most  important  elements  in  the  sexual 
act  is  active  hyperemia  of  the  prostate,  and  it  seems  plausible,  from  this  fact 
alone,  that  excessive  indulgence  may  produce  permanent  injury.  Should 
sexual  excess  be  alternated  with  prolonged  and  ungratified  sexual  desire,  a 
permanent  impression  is  still  more  likely  to  result.     Constant  overstimula- 


ETIOLOGY    OF    HYPEETEOPHY    OF    THE    PEOSTATE.  691 

tion  of  the  glandular  function  of  the  prostate  is  a  very  important  element 
for  consideration. 

Enlargement  of  the  prostate  produced  by  chronic  hyperemia  is  usually 
of  no  particular  importance  during  youth  or  early  adult  life.  This  is  prob- 
ably explicable  by  the  relief  afEorded  by  free  secretion,  the  elasticity  of  the 
tissues  themselves,  and  the  fact  that  the  bladder  retains  its  normal  tonus. 
When,  however,  the  individual  passes  the  prime  of  life  and  his  tissues  be- 
come less  resilient,  and  secretion  in  general  less  active,  there  is  scantier  se- 
cretion, with  diminished  activity  of  the  return-circulation,  and  the  hyper- 
emia is  not  relieved. . 

Few  modern  authorities  attribute  so  much  importance  to  prolonged 
irritation  and  habitual  engorgement  of  the  prostate  from  various  causes  as 
did  the  elder  Gross,  but  it  is  the  author's  opinion  that  the  views  of  this 
distinguished  surgeon  were  based  upon  sound  reasoning  and  accurate  clin- 
ical observation.  Any  condition  of  the  urethra  giving  rise  to  prostatic  irri- 
tation and  hyperemia,  or  to  actual  inflammation,  may  lead  to  permanent 
irritability  of  the  vesical  neck,  with  a  resulting  increase  in  frequency  of 
urination,  which  may  become  permanent.  It  seems  reasonable  that  this  may 
produce  hypertrophy  of  the  overworked  prostate  later  in  life  when,  as  is 
likely  to  be  the  case,  undue  sexual  excitement  or  indulgence  co-exists  with 
the  urinary  irritation.  The  gouty  and  rheumatic  diatheses  probably  bear  a 
subordinate  relation  to  the  etiology  of  hypertrophy  of  the  prostate  in  certain 
cases. 

In  a  general  way,  it  may  be  said  that  the  various  etiologic  factors  out- 
lined are  productive  of  "prostatic  overstrain,"  which  bears  the  same  relation 
to  prostatic  hypertrophy  that  a  long-forgotten  strain,  experienced  during 
early  life,  sometimes  does  to  a  stiffened  and  thickened  joint  in  the  aged. 
It  is  a  matter  of  common  experience  that  when  the  tissues  begin  to  lose 
the  elasticity  of  youth,  when  joints  begin  to  grow  less  mobile  and  a  tend- 
ency to  rheumatoid  pains  and  other  senile  diificulties  develops,  special  com- 
plaint is  likely  to  be  made  of  so-called  rheumatism  or  rheumatoid  arthritis 
limited  to  some  joint  that  suffered  an  injury  at  some  remote  period. 
Many  injuries  experienced  in  youth  and  long  forgotten  are  called  to  mind 
by  some  pathologic  condition  supposedly  incident  to  senility.  It  is  hardly 
conceivable  that  so  large  a  proportion  of  men  would  develop  prostatic  hy- 
pertrophy if  there  were  not  such  special  causes  for  the  condition  as  those 
above  mentioned.  Prostatic  hypertrophy  is  certainly  not  a  natural  con- 
comitant of  advanced  life,  and  it  is  probable  that  the  causes  outlined  bear 
the  same  relation  to  it  that  frequent  child-bearing  does  to  certain  pathologic 
conditions  of  the  uterus.  It  is  noteworthy  that  the  majority  of  authorities 
who  do  not  frankly  acknowledge  their  inability  to  assign  the  disease  to  any 
particular  cause  dwell  with  greater  or  less  emphasis  on  the  dependence  of 
the  disease  upon  conditions  that  produce  irritation  and  hyperemia  of  the 
organ. 


692  HTPERTEOPHT    OF    THE    PEOSTATE. 

Prostatic  enlargement,  as  shown  in  the  resume  of  etiologic  opinions, 
has  been  attributed  to  urethral  stricture.  Stricture  is  undoubtedly  capable 
of  producing  chronic  congestion  and  hyperplasia  of  the  prostate — i.e.,  over- 
strain with  resulting  circulatory  disturbance  and  associated  infection. 
Paradoxic  as  it  may  seem,  however,  the  danger  of  resulting  prostatic  hyper- 
trophy is  inversely  to  the  degree  of  obstruction.  Strictures  of  large  caliber 
in  the  penile  urethra  produce  proportionately  greater  reflex  disturbance  of 
the  prostate  than  deep  strictures  of  small  caliber.  A  man  who  at  the  age 
of  from  thirty  to  forty  develops  a  tight  stricture  in  the  deep  urethra  is 
likely  to  be  perfectly  protected  from  enlarged  prostata  in  after-life.  Irri- 
tation and  congestion  of  the  prostate  occur,  it  is  true,  but  hyperplasia  of 
the  portion  of  the  organ  most  likely  to  produce  urinary  obstruction  is  pre- 
vented by  the  pressure  of  the  urine  in  the  prostatic  urethra  during  micturi- 
tion. The  author's  experience  in  the  performance  of  perineal  section  upon 
tight  strictures  in  the  musculo-membranous  region  is  that  the  prostatic 
urethra  is  often  greatly  dilated,  apparently  at  the  expense  of  the  prostate 
itself,  or  at  least  that  portion  immediately  contiguous  to  the  mucous  mem- 
brane lining  the  prostatic  urethra.  The  effects  of  pressure  in  producing 
relative  prostatic  atrophy  are  well  shown  in  cases  of  calculi  that  become 
lodged  in  the  prostatic  urethra.  There  may  be,  it  is  true,  compensatory 
hypertrophy  of  the  remaining  fibers  of  the  prostate,  but  we  must  not  forget 
what  seems  to  be  a  logical  analogy,  viz.:  cardiac  hypertrophy  followed  by 
extreme  dilation  resulting  from  obstructive  valvular  lesions. 

Varieties.  —  Hypertrophy  of  the  prostate  presents  itself  in  several 
different  forms,  depending  mainly  upon  the  arrangement  of  the  elements 
of  the  abnormal  growth.     In  general,  the  varieties  are:— 

1.  Diffuse  enlargement  associated  with  vesical  atheroma.  Exception- 
ally, circumscribed  development  of  the  posterior  median  portion  or  one  or 
both  lateral  lobes  may  be  associated  with  the  atheroma.  As  a  rule,  however, 
where  vesical  atheroma  is  found,  the  prostate  is  uniformly  enlarged.  The 
thickening  of  the  bladder,  especially  that  portion  immediately  contiguous 
to  the  prostate,  is  likely  to  be  considerable,  the  vasa  deferentia  and  seminal 
vesicles,  and  possibly  the  ureters,  participating  in  the  atheroma,  the  con- 
nective tissue  enveloping  these  structures  being  greatly  thickened  and  gristly 
or  semieartilaginous.  Eigid  columns  of  atheromatous  deposit  may  project 
into  the  bladder.  In  some  instances  such  pillars  correspond  to  the  course 
of  the  ureters  and  vasa  deferentia.  A  bar  between  the  ureteral  orifices  is 
common  in  this  condition.  The  author  has  found  that  many  cases  of  ves- 
ical atheroma  are  associated  with  fatt}'  degeneration.  In  one  case,  dead  of 
hepatic  cirrhosis,  there  was  no  cystitis,  but  the  bladder  was  extensively 
dilated,  and  both  bladder  and  prostate  were  involved  in  pronounced  diffuse 
fatty  degeneration.  The  normal  elements  were  almost  entire!}^  replaced  by 
fat. 


VAEIETIES    OF    HYPEETKOPHY    OF    THE    PEOSTATE. 


693 


2.  Hypertrophy  of  both  lateral  lobes,  the  median  portion  remaining 
comparatively  normal. 

3.  Hypertrophy  of  both  lateral  lobes  associated  with  posterior  median 
hypertrophy — so-called  hypertrophy  of  the  middle  lobe. 

4.  Hypertrophy  of  one  lateral  lobe  associated  with  posterior  median 
hj^pertrophy. 

5.  Posterior  median  hypertrophy  with  little  or  no  enlargement  of  the 
rest  of  the  organ.  It  may  present  a  quite  acute  median  prominence  or  may 
be  irregular,  filling  up  the  vesico-urethral  orifice  and  projecting  to  one  or 
the  other  side. 

6.  Hypertrophy  of  the  anterior  portion  of  the  prostatic  floor.     This 


Fig.  131. — An  example  of  gveatly-enlaiged  jM'ostate,  mainly  due  to  fibrous 
tumors.     (After  Holmes.) 


may  or  may  not  be  associated  with  lateral  hypertrophy,  of  one  or,  more  fre- 
quently, both  lobes. 

7.  Some  form  of  prostatic  hypertrophy  associated  with  bar  at  the  neck 
of  the  bladder. 

8.  Distinct,  circumscribed,  adenomatous,  fibro-adenomatous,  or  fibro- 
myomatous  tumors  occurring  in  the  substance  of  the  prostate.  These  are 
somewhat  analogous  to  the  fibromyomatous  neoplasia  that  develop  in  the 
uterus.  When  these  new  growths  occur  in  the  floor  of  the  prostatic  urethra 
they  may  form  quite  distinct  pedunculated  tumors.  In  some  instances  they 
project  from  the  posterior  median  portion  into  the  bladder  and  act  like  a 
ball- valve  in  producing  urinary  obstruction. 

When  the  prostate  is  diffusely  hypertrophied  the  mass  may  not  cause  so 


694 


HYPEETEOPHY    OF    THE    PEOSTATE. 


much  difficulty,  even  Avhen  very  large,  as  that  produced  by  irregular  develop- 
ment associated  with  deviation  of  the  prostatic  urethra  and  obstruction  of 
the  vesical  neck.  It  seems  to  be  the  variety  rather  than  the  degree  of  en- 
largement that  is  most  important.  Extensive  diffuse  enlargement  may  be 
tolerated,  while  a  very  small  median  obstruction  gives  rise  to  great  annoyance. 
In  many  cases  of  prostatic  hypertrophy  the  process  is  probably  adenomatous 
at  the  beginning,  affecting  only  the  glandular  and  periglandular  tissues. 
Fibrosclerotic  changes  develop  later  on,  and  eventually  the  enlargement 
assumes  a  fibro-adenomatous  character.  In  all  varieties  of  prostatic  hyper- 
trophy there  is  probably  not  only  hypertrophy  of  the  elements  of  the  organ, 
but  true  hyperplasia,  which,  primarily  at  least,  is  the  predominating  condi- 
tion.   It  is  questionable  whether  the  process  should  not  be  termed  hyper- 


Fig.   132. — Pedunculated,  "middle   lobe"   obstructing   catheter. 
(After  Erichsen.) 

plasia  rather  than  hypertrophy  of  the  prostate.  The  increase  in  bulk  is 
certainly  due  more  especially  to  increase  of  the  normal  tissue-elements 
rather  than  to  their  exaggerated  development. 

The  most  frequent  variety  of  prostatic  enlargement  is  posterior  median 
hypertrophy,  with  or  without  enlargement  of  the  lateral  lobes,  constituting 
the  so-called  middle  lobe.  This  is  also  the  most  important  form  because 
comparatively  slight  overgrowth  in  this  situation  produces  mechanic  ob- 
struction and  irritation  of  the  vesical  neck  that  are  greatly  disproportionate 
to  the  degree  of  enlargement.  The  physical  characters  of  median  hyper- 
trophy vary  considerably.  Distinct  fibro-adenomatous  overgrowth  of  pe- 
dunculated form  is  sometimes  met  with.  As  already  suggested,  this  may 
have  a  valve-like  action,  producing  intermittence  of  the  stream  during 
micturition,  with  perhaps  more  or  less  spasmodic  action  of  the  parts  about 


VARIETIES    OF    HTPERTEOPHT    OF   THE    PEOSTATE. 


6,95 


the  neck  of  the  bladder  strongly  siTggestive  of  vesical  calculus.  Other 
things  being  equal,  this  form  of  hypertrophy  is  quite  amenable  to  sur- 
gical interference,  inasmuch  as  the  necessary  operation  is  very  simple,  and, 
if  performed  at  an  early  period  before  the  kidneys  are  extensively  diseased, 
likely  to  be  successful.  Whether  pedunculated  or  not,  the  overgrowth  in 
posterior  median  hypertrophy  projects  backward  and  upward,  producing 
serious  mechanic  disturbance  at  the  vesical  neck. 

Some  theorizing  has  been  done  upon  the  causes  of  the  transformation 
of  posterior  median  overgrowths  into  polypoid  tumors.  It  has  been  as- 
serted that  mechanic  squeezing  during  frequent,  painful,  and  more  or  less 
spasmodic  efforts  at  micturition  is  responsible  for  their  jutting  out  and 


I 


Fig.  133. — Enlargement  of  "middle  lobe."     (After  Coulson.) 

eventual  pedunculation.  This  explanation  is  logical,  especially  where  the 
point  of  departure  of  hypertrophy  is  thoroughly  circumscribed  in  the  poste- 
rior median  portion  of  the  organ. 

The  term  median  lobe  is  unfortunate,  as  it  may  lead  to  the  supposition 
that  a  third  or  middle  lobe  exists  in  the  normal  prostate,  when,  as  a  matter 
of  fact,  the  projecting  growth  is  invariably  pathologic,  being  probably  due 
primarily  to  circumscribed  hyperplasia  of  the  posterior  portion  of  the  floor 
of  the  prostatic  urethra.  This  part  of  the  organ  is  important  in  its  relations 
to  the  sexual  function,  and  it  is  possible  that  the  frequent  limitation  of  pro- 
static hypertrophy  to  this  region  is  an  evidence  of  the  causal  relations  of 
aberrations  of  sexual  physiology  to  the  disease.  In  general,  whatever  the 
form  of  hypertrophy,  it  produces  its  most  serious  effects  by  mechanically 


696 


HYPEETEOPHY    OF    THE    PEOSTATE. 


obstructing  the  urinar}-  outflow.  Marked  secondar}'  changes  in  the  vesical 
floor  are  chiefly  dependent  upon  this  mechanic  obstruction.  The  pouching 
of  the  vesical  walls  in  the  vicinity  of  the  trigone  known  as  the  has-fond,  or 
lower  bottom^  depends  for  its  formation  chiefly  upon  intravesical  pressure 
incidental  to  mechanic  obstruction  of  the  vesical  neck. 

Thompson  presents  four  varieties  of  hypertroj^hy^  according  to  the 
relative  degree  of  involvement  of  the  several  structures  of  the  prostate,  viz.: 
1.  Simple  increase  in  development  involving  all  the  component  tissues  of 
the  organ  in  about  equal  ratio.  2.  Excess  of  development  of  stromal  and 
fibrous  structure  (i.e.,  pale,  muscular  fiber;  connective  and  elastic  tissue) 
over  the  glandular.  3.  Excess  of  development  of  the  glandular  portion  (i.e., 
basement-membrane,  follicles;  excretory  ducts,  and  epithelium)  over  the 
stromal.  4.  Eearrangement  of  the  structures,  stromal  and  glandular,  in 
the  form  of  circumscribed  tumor.    Of  these  varieties  the  second,  or  stromal^ 


Fig.  134. — Adenomatous  tumor  from  left  lobe  of  prostate  removed  by  com- 
bined suprapubic  and  perineal  sections.  Natural  size.  (Author's 
ease.) 

variety  is  the  most  frequent.  Thompson  states  that  of  seventy  specimens 
of  hypertrophied  prostate  in  the  Museum  of  the  Eoyal  College  of  Surgeons 
in  seventeen  there  were  isolated  tumors  that  were  clearly  discernible.  These 
tumors  he  divides  into:  1.  Those  imbedded  in  the  substance  of  the  organ, 
but  isolated  from  the  structures  surrounding  it.  2.  Tumors  continuous  in 
structure  with  the  portion  of  the  prostate  from  which  they  spring,  but  which 
manifest  a  tendency  to  partial  isolation  by  becoming  more  or  less  polypoid,, 
maintaining  attachment  to  the  parent-organ  by  a  pedicle  only. 

The  structure  of  some  cases  of  isolated  tumor  approximate  myofibroma 
very  closely.  Indeed,  Eokitansky  formerly  considered  these  tumors  to  be 
simple  fibrous  formations  similar  to  fibroids  occurring  in  other  portions  of 
the  body.  Upon  careful  examination  their  structure  is  usually — according 
to  some  authorities  always — found  to  be  quite  similar  to  that  of  the  rest 
of  the  hypertrophied  organ:    i.e.,  fibro-adenomatous,  but  with  little  mus- 


COMPLICATIOX    IX    HTPERTKOPHT    OF    THE    PEOSTATE. 


69' 


cular  tissue.  They  are  often,  however,  completely  isolated  by  a  true  fibrous 
capsule,  from  which  they  may  be  readily  shelled  out.  It  is  not  unusual  to 
find  circumscribed  posterior  median  growths  covered  apparently  only  by 
vesical  mucous  membrane,  which  are  readily  shelled  out  with  the  finger 
after  incision  of  the  overlying  tissues.  In  a  recent  operation  the  author 
removed  a  growth  of  this  kind  suprapubically  with  the  index  finger,  with 
very  little  force  and  without  any  preliminary  cutting.  These  growths  re- 
semble typic  adenoma  rather  than  fibromyoma. 

Dimensions. — The  size  of  the  hypertrophied  prostate  varies  consider- 
ably.   Thompson  records  a  case  in  which  the  transverse  diameter  exceeded 


Fig.  135. — Enlargement  of  the  lateral  lobes,  with  incipient  increase  in  size 
of  middle  lobe,  and  a  bar  or  ridge  at  the  neck  of  the  bladder  through 
which  a  false  passage  has  been  made.     (After  Coulson.) 


4  ^/2  inches,  the  weight  being  about  13  ounces.  He  says,  however,  that 
such  a  size  is  rarely  attained,  although  a  diameter  of  3  inches  is  not  un- 
common. As  a  rule,  the  enlargement  is  rather  moderate.  As  already  indi- 
cated, considerable  enlargement  may  exist — if  the  organ  be  uniformly  in- 
volved— without  producing  marked  symptoms,  a  relatively  small  enlarge- 
ment of  the  so-called  median  lobe  being,  however,  sufficient  to  produce 
considerable  anno3^ance. 

Complicating  Bar. — There  occurs  in  some  cases  as  a  consequence  of 
hypertrophy  of  the  prostate  what  was  first  denominated  by  Gruthrie  as  "hdiV 
at  the  neck  of  the  bladder."  The  classic  form  of  this  disease  may  occur 
independently  of  prostatic  hypertrophy  from  enlargement  of  the  muscular 


698  HTPEETEOPHY    OF    THE    PEOSTATE. 

fibers  traversing  the  trigone  just  posterior  to  the  prostate.  As  a  consequence 
of  this  enlargement  the  bundle  of  muscular  fibers  projects  from  the  floor 
of  the  bladder,  causing  decided  obstruction  to  the  flow  of  urine.  Prostatic 
hypertrophy  proper  produces  bar  at  the  neck  of  the  bladder  in  two  ways, 
viz.:  (a)  The  prostatic  hypertrophy  is  circumscribed,  running  transversely 
across  the  floor  of  the  prostatic  urethra  without  forming  a  definite  tumor- 
mass.  (&)  Two  portions  (lobes)  of  the  hypertrophied  prostate  project  in 
such  a  manner  that  the  mucous  membrane  is  stretched  across  the  neck  of 
the  bladder  between  them. 

In  some  cases  the  bar  is  seemingly  due  to  general  vesical  atheroma, 
being  associated  with  columnar  formation  of  hyperplasic  tissue  in  the  course 
of  the  ureters.  It  may  form  in  young  and  otherwise  healthy  bladders;  the 
author  has  seen  one  specimen  of  bar  in  a  subject  two  years  of  age.  This  was 
undoubtedly  congenital. 

Frequency. — Thompson  concludes  as  follows:  1.  Enlargement  of  the 
prostate  in  a  moderate  degree  occurs  in  one  out  of  every  three  individuals 
at  middle  age.  (Reginald  Harrison  also  states  that  one-third  of  the  male 
population  of  the  world  who  have  passed  the  age  of  55  years  are  the  sub- 
jects of  prostatic  hypertrophy.)  2.  Thirty  per  cent,  of  men  above  50  years 
of  age  have  "fibrous  tumors"  of  the  prostate.  3.  After  the  age  of  50  one 
man  in  every  eight  has  marked  enlargement,  but  exceptionally  before  the 
age  of  60.    4.  The  disease  rarely  begins  later  than  70  years  of  age. 

MoEBiD  Anatomy. — The  hypertrophied  prostate  is  usually  hard  and 
indurated  as  compared  with  the  normal  consistency  of  the  organ.  Some- 
times, on  the  other  hand,  although  considerably  enlarged,  its  texture  is 
comparatively  soft  and  loose.  This  condition  is,  however,  rarely  found 
save  in  cases  not  far  advanced.  The  more  indurated  variety  is  often  asso- 
ciated with  atheroma. 

The  varying  forms  of  hypertrophy  have  already  been  noted.  The 
most  frequent  variety  of  enlargement  from  an  anatomic  stand-point  is  that 
in  which  the  organ  is  uniformly  involved.  Clinically,  however,  median  hy- 
pertrophy is  most  frequently  met  with  because  of  its  invariably  disagree- 
able results.  Individuals  with  moderate  general  enlargement  of  the  pros- 
tate may  live  to  an  advanced  age  without  ever  experiencing  sufficient  dis- 
comfort to  demand  the  aid  of  the  surgeon.  As  a  corollary,  it  is  obvious 
that,  in  the  majority  o!E  cases  presenting  themselves  to  our  observation,  we 
are  justified  in  assuming  that  median  hypertrophy  exists.  The  three  patho- 
logic divisions  of  the  prostate — i.e.,  the  median  and  two  lateral  lobes — may 
be  so  greatly  enlarged  as  to  form  three  tolerably  distinct  tumors  jutting 
out  from  the  main  body  of  the  prostate  that  are  very  apt  to  be  associated 
with  bar  at  the  vesical  neck. 

As  a  consequence  of  the  enlargement  of  the  organ  the  prostatic  urethra 
is  increased  in  length  and  its  curve  is  exaggerated.  If  the  enlargement  is 
at  all  irregular  or  asymmetrical  the  canal  is  tortuous.    The  elasticity  of  the 


MOEBID    ANATOMY   OF    HYPEKTROPHT    OF    THE    PROSTATE.  699 

prostatic  urethra  is  necessarily  impaired  in  all  cases.  The  increased  length 
of  the  urethra  is  a  most  important  consideration  in  the  surgery  of  the  part, 
inasmuch  as  it  becomes  necessary  to  adapt  the  curve  and  method  of  intro- 
duction of  instruments  used  in  treatment  to  the  abnormal  form  of  the  canal. 
On  section  the  organ  is  usually  found  to  be  quite  hard,  pale,  and  compara- 
tively bloodless.  There  is  in  most  cases  an  evident  increase  of  all  the 
elements  of  the  organ,  more  especially  the  muscular  and  fibrous  stroma. 
This  hyperplasia  is,  in  the  opinion  of  the  author,  the  most  important  factor 
of  the  disease.  As  already  stated,  isolated  tumors,  simulating  myomata  (?) 
or  fibro-adenomata,  may  be  found,  in  some  cases  surrounded  by  a  distinct 
capsule  and  in  others  not  so  readily  outlined.  Prostatic  concretions  may  be 
present,  and  if  numerous  they  may  be  contained  in  a  sort  of  sac  produced 
by  absorption  of  the  tissue  of  the  prostate  by  the  pressure  of  the  calculi. 
These  calculi  may  be  found  outside  the  prostate  proper,  in  the  glandular 
tissue  about  the  vesical  neck. 

The  floor  of  the  bladder  behind  the  prostate  is  dilated,  often  thinned, 
but  sometimes  thickened  by  atheroma,  forming  the  depression  already  al- 
luded to  as  the  las-fond.  This  is  found  in  advanced  cases  to  contain  more 
or  less  fetid  and  ammoniacal  urine  mixed  with  mucus,  pus,  and  triple  phos- 
phates. In  many  instances  a  definite  calculus  is  found.  The  occurrence  of 
phosphatic  calculi  in  cases  of  prostatic  disease  is  readily  explained:  As  a 
consequence  of  decomposition  of  residual  urine,  more  or  less  phosphatic 
material  is  formed;  this  deposits  upon  a  mass  of  muco-pus  secreted  by  the 
inflamed  bladder  or  upon  a  blood-clot  and  solidifies,  the  process  being  pre- 
cisely similar  to  the  crystallization  of  sugar.  When  once  a  small  calculus 
has  formed  it  grows  with  considerable  rapidity;  it  enhances  the  inflamma- 
tion and  increases  the  secretion  of  muco-pus  and  deposition  of  phosphates, 
enlarging  very  much  like  a  rolling  snow-ball,  layer  after  layer  of  phosphatic 
material  being  deposited  upon  its  surface  until  finally  in  some  instances  an 
almost  incredible  size  is  attained.  The  nucleus  may  be  formed  by  insoluble 
drugs  or  foreign  bodies  introduced  into  the  bladder,  or  may  consist  of  uric 
acid  or  urates.  The  typic  calculus  of  prostatiques,  however,  is  phosphatic. 
The  bladder,  as  a  consequence  of  obstruction  to  the  urinary  outflow,  under- 
goes compensatory  hypertrophy,  and  eventually  its  mucous  membrane  be- 
comes inflamed,  presenting  the  ordinary  appearances  of  chronic  cystitis. 

The  associated  pathologic  conditions  of  the  genito-urinary  tract  above 
the  prostate  naturally  demand  consideration  in  connection  with  the  morbid 
anatomy  of  prostatic  hypertrophy.  These  conditions  are  mainly  secondary 
to  the  prostatic  disease,  varying  in  degree  according  to  the  variety  and  ex- 
tent of  obstruction  and  dependent  more  particularly  upon  the  presence  or 
absence  as  well  as  the  duration  and  severity  of  secondary  infection.  The 
mechanic  disturbance  produces  in  the  first  instance  serious  disturbance  of 
the  return  venous  flow.  Vesical  hyperplasia  and  congestion  of  the  mucous 
membrane,  with  excessive  formation  of  mucus,  is  the  natural  result.     In 


700 


HYPEKTEOPHY    OF    THE    PEOSTATE. 


some  instances  the  bladder  becomes  enormously  tbickened  as  a  consequence 
of  freqnent  and  forcible  efforts  at  micturition:  interstitial  proliferation  of 
connective  tissue  occurs  and  the  bladder  finally  contracts  down  into  a  hard 
mass  little  resembling  the  normal  viscus,  the  capacity  of  which  may  be 
but  a  few  drams.  In  other  instances  as  a  consequence  of  attacks  of  reten- 
tion superadded  to  continual  obstruction  to  the  urinary  outflow,  the  blad- 
der becomes  atonic,  dilated,  and  presents  a  trabeculated  appearance  from 
hypertrophy  of  the  fasciculi  of  muscular  fibers  composing  its  walls.  The 
portions  of  bladder-wall  between  these  bundles  of  muscular  fibers  are  rela- 
tively thinned,  dilated,  and  perhaps  sacculated,  the  sacculi  containing  de- 
composing urine,  muco-pus,  phosphates,  and  perhaps  one  or  more  calculi, 


Fig.  1.36. — Hvpertrophv,  fasoiculation.  and  sacculation  of  vesical  walls  from 
median  prostatic  obstruction.     (After  Moullin.) 


presenting,  in  short,  the  same  conditions  as  does  the  las-fond  in  the  pres- 
ence of  septic  cystitis. 

The  mechanic  effect  of  prostatic  hypertrophy  extends  farther  than  the 
bladder  and  involves  the  ureters  and  kidneys.  These  may  be  dilated  and 
thickened.  The  kidney  presents  more  or  less  thinning  of  its  cortex,  with 
dilation  of  its  jDclvis.  These  results  occur  sooner  or  later,  whether  or  not 
infection  of  the  bladder  is  superadded.  The  disturbance  of  renal  nutrition 
incidental  to  this  dilation  and  thinning  from  the  backward  urinar}'  press- 
ure affords  a  locus  minoris  resistentice  extremel}'  favorable  to  bacterial  in- 
fection. The  slightest  degree  of  hyperemia  superadded  to  this  condition 
may  completely  suspend  the  already  more  or  less  inhibited  function  of  renal 
secretion,  with  resulting  uremia  and  speedy  death.  The  impairment  of 
function  incidental  to  the  chronic  condition  produced  by  the  urinary  ob- 


SYMPTOMS    OF    HYPEETEOPHY    OF    THE    PEOSTATE.  701 

struction  necessarily  results  in  a  greater  or  less  degree  of  nrinar}^  empoison- 
ment  of  the  general  system. 

The  septic  effects  of  prostatic  hypertrophy  are  attributable  directly  or 
indirectly  to  bacterial  infection.     The  congested,   hypersecreting  yesical 
mucous  membrane  affords  a  favorable  soil  for  bacterial  infection;    the  se- 
creted mucus  favors  chemic  changes  in  the  urine.    The  collection  of  residual 
urine  in  the  has-fond  behind  the  obstruction  is  more  or  less  stagnant  as  a 
consequence  of  imperfect  emptying  of  the  bladder,  and  very  readily  under- 
goes decomposition  under  favorable  circumstances  of  bacterial  infection. 
The  circumstances  necessary  for  infection  are  almost  invariably  afforded  by 
septic  catheterization  either  by  the  patient  or  his  physician.     Consequent 
upon  the  infection  is  cystitis  with  ammoniacal  decomposition  of  urine.    In- 
fection in  extreme  cases  travels  along  the  ureter  to  the  kidney,  setting  up 
septic  pyelitis  and  finally  pyelonephritis.    The  process  develops  so  gradually 
that  the  patient  may  tolerate  it  for  a  prolonged  period.    In  some  instances 
the  urine  appears  so  nearly  normal  when  freed  from  the  products  of  mu- 
cous inflammation  that  serious  renal  disease  is  not  suspected.     The  degree 
of  renal  involvement  compatible  with  life  is  in  these  cases  something  ex- 
traordinary.    The  patient  may  tolerate  his  pyelonephritis  for  a  prolonged 
period  and  may  appear  to  be  a  favorable  subject  for  operation.     Operative 
shock  and  anesthesia,  with  sudden  cessation  of  intrarenal  pressure  from  re- 
lief to  the  urinary  obstruction,  however,  precipitate  acute  hyperemia  of  the 
already  damaged  kidne}^,  and  the  patient  dies,  the  post-mortem  examination 
showing  that  but  a  very  small  proportion  of  renal  cortex  remain.s,  and  this  is 
so  damaged  that  it  is  extra ordinar}^  that  the  patient  should  have  been  able  to 
endure  it  for  so  long  a  time.    The  gradual  development  of  the  process,  with 
relatively  slow  general  tissue-metabolism  and  a  certain  degree  of  acquired 
tolerance  of  urinary  toxemia,  is  the  probable  explanation.     The  joractical 
jDoint  that  the  author  desires  to  impress  is  that  serious  impairment  of  the 
kidneys  is  inevitable  in  all  cases  of  prostatic  hypertrophy  producing  even 
moderately  serious  obstruction  to  the  urinary  outflow,  if  the  obstruction 
continues  for  any  great  length  of  time.     In  long-standing  cases  in  which 
operation  is  proposed  the  existence  of  serious  impairment  of  the  structure 
and  function  of  the  kidneys  is  to  be  taken  for  granted,  the  condition  of  the 
urine  to  the  contrary  notwithstanding. 

Symptoms.  —  The  symptoms  of  prostatic  hypertrophy  are  obviously 
those  incidental  to  (a)  urinary  obstruction,  (h)  the  various  conditions  sec- 
ondary to  obstruction,  and  (c)  conditions  ingrafted  upon  obstruction  by 
infection.  Hypertrophy  must  necessarily  exist  in  many  instances  long  be- 
fore symptoms  are  produced.  The  condition  is  not  painful  per  se,  and  there 
may  be  no  evidence  of  its  existence  until  sufficient  size  has  been  attained 
to  produce  mechanic  interference  with  the  function  of  urination.  In  quite 
a  proportion  of  cases,  however,  more  or  less  symptoms  referable  to  the  ves- 
ical neck  exist  for  some  years  before  appreciable  obstruction  occurs. 


703  HYPEETROPHT    OF   THE    PEOSTATE. 

As  the  prostate  is  one  of  the  principal  factors  in  the  coup  de  piston, — - 
i.e.,  the  spasmodic  contraction  of  the  urethral  and  cut-off  muscles  that  ex- 
pels the  final  drops  of  urine  or  semen  from  the  urethra^, — one  of  the  first 
symptoms  of  prostatic  hypertrophy  is  difficulty  in  clearing  the  canal  of 
fluid.  Obviously,  whether  the  prostate  is  an  active  participant  in  the  proc- 
ess of  closing  the  neck  of  the  bladder  at  the  termination  of  urination  or  not, 
it  must  necessarily  interfere  with  this  process  when  it  becomes  rigid  and 
enlarged,  by  resisting  the  pressure  of  the  cut-off  muscle.  The  patient  soon 
notices  a  little  tardiness  in  the  commencement  of  the  flow  and  a  lack  of 
force  of  the  stream  of  urine.  The  explanation  of  this  is  very  simple.  Under 
normal  conditions  there  is  nothing  to  retard  the  flow  of  urine  after  the  cut- 
off muscle  has  been  voluntarily  relaxed,  the  prostate  being  elastic  and  dis- 
tensible. When,  however,  it  has  become  rigid  and  inelastic  it  opposes  the 
action  of  the  deirusor-urince  muscle  and  inhibits  micturition  to  a  certain 
degree.  This  alone  suffices  to  induce,  sooner  or  later,  compensatory  hyper- 
trophy of  the  vesical  walls.  The  stream  of  urine  may  be  slightly  smaller 
than  normal,  but,  as  a  rule,  it  is  not  appreciably  changed:  a  very  impor- 
tant point  in  differentiating  this  condition  from  urethral  stricture.  Pouch- 
ing of  the  bladder  at  the't as-fond  occurs  in  many  cases  before  symptoms  are 
manifest;  hence  the  bladder  is  never  entirely  empty,  a  few  drops  of  urine 
accumulating  in  the  pouch  quite  early  in  the  course  of  the  case.  If  bac- 
teria enter  the  bladder  this  urinary  residium  decomposes,  causing  irritation 
and  catarrh  of  the  vesical  mucosa,  with  a  resultant  feeling  that  the  blad- 
der has  not  been  entirely  emptied.  The  author  desires  to  emphasize  the 
fact  that  it  is  not  the  residual  urine  per  se  that  produces  the  irritation;  it  is 
tolerated  unless  infected.  As  the  case  goes  on  and  infection  occurs,  the 
calls  to  micturate  become  more  frequent.  A  sense  of  fullness  and  discom- 
fort in  the  perineum  and  rectum  are  experienced  after  a  time,  this  symp- 
tom being  aggravated  during  and  after  stool,  particularly  if  the  bowels  be 
constipated.  There  may  be  so  much  irritation  about  the  parts  that  the 
nerves  of  sexual  sensibility  are  affected,  with  resultant  priapism.  Extreme 
libidinousness  in  old  men  is  usually  due  to  hypertrophy  of  the  prostate.  In 
some  cases  impotence  results. 

As  the  case  progresses  the  cystitis  becomes  more  marked,  the  has-fond 
increasing  in  depth,  with  resulting  increase  of  residual  urine.  The  obstruc- 
tion at  the  vesical  neck  finally  becomes  so  marked  that  the  organ  contains 
quite  a  quantity  of  urine  after  the  patient  has  apparently  emptied  it.  It 
is  sometimes  a  matter  of  svirprise  to  the  patient,  especially  if  he  consults  a 
surgeon  early  in  the  course  of  the  case,  to  find  that  it  is  possible  to  draw 
off  a  large  quantity  of  urine  with  the  catheter  when  he  supposes  that  he 
has  emptied  the  bladder  completel5^ 

Incontinence  of  urine,  especially  at  night,  is  a  frequent  symptom.  It 
is  due  to  overfiow  of  the  distended  bladder  at  a  time  when  the  tonicity  of 
the  cut-off  muscle  is  interfered  with.     The  normal  tonicity  of  this  complex 


SYMPTOMS    OF   HTPERTEOPHY    OP    THE    PEOSTATE.  703 

muscle,  in  combination  with  the  volitional  power  of  the  patient,  is  suffi- 
cient to  prevent  dribbling  of  urine  (save  after  prolonged  retention)  in  the 
day-time.  When,  however,  volition  is  inhibited  by  sleep,  overflow  may  oc- 
cur. Another  cause  for  nocturnal  incontinence  is  the  reflex  effort  of  the 
bladder  to  empty  itself  under  the  stimulus  of  inflammation  about  the  ves- 
ical neck.  A  point  that  has  hardly  received  sufficient  attention  is  the  fact 
that  when  the  prostate  is  uniformly  enlarged  the  neck  of  the  bladder  loses 
its  contractility,  and  becomes  more  patulous  than  normal,  although  it  may 
appear  contracted  on  account  of  the  loss  of  elasticity.  The  condition  is 
very  similar  to  what  would  occur  from  the  substitution  of  a  small,  but  rigid 
and  inelastic,  tube  for  a  comparatively  large,  elastic,  and  contractile  one. 
Attacks  of  complete  retention  eventually  occur  from  time  to  time;  these 
are  usually  superinduced  by  acute  congestion  of  the  prostate  and  vesical 
neck  incidental  to  excesses  in  eating,  drinking,  sexual  indulgence,  or  to 
exposure  to  wet  and  cold,  particularly  if  the'  lower  extremities  become 
chilled.  The  pain  and  prostration  due  to  retention  are  apt  to  be  entirely 
disproportionate  to  the  amount  of  urine  contained  in  the  bladder;  some 
patients  suffer  severely  from  the  retention  of  a  comparatively  small  quan- 
tity of  urine,  while  others  will  passively  permit  the  bladder  to  become  enor- 
mously distended  without  sending  for  aid.  The  author  recalls  an  interest- 
ing case  that  bears  upon  this  point.  The  patient  was  a  gentleman,  75  years 
of  age,  who  had  suffered  for  years  from  enlargement  of  the  prostate  with 
occasional  attacks  of  retention.  On  this  occasion,  as  a  consequence  of  slight 
exposure,  he  found  himself  unable  to  urinate,  the  retention  being  associated 
with  excruciating  pain  and  vesical  tenesmus.  He  was  greatly  prostrated  by 
his  suffering,  but  stated  that  he  had  passed  urine  four  or  five  hours  be- 
fore. The  catheter  showed  that  the  bladder  did  not  contain  more  than 
a  pint  of  comparatively  healthy  urine.  Cases  of  this  kind  are  due  to  acute 
hyperemia,  of  the  prostate  and  vesical  neck,  causing  these  parts  to  become 
extremely  hyperesthetic.  It  is  to  be  remembered  in  this  connection  that  cases 
occasionally  arise  in  which  the  bladder  becomes  immensely  hypertrophied 
and  contracted,  so  that  it  will  contain  but  a  few  drams  of  urine.  Such  cases, 
however,  do  not  present  the  clinical  features  of  the  case  in  question,  in  which 
the  bladder  was  very  tolerant  of  urine  so  long  as  it  was  evacuated  at  proper 
intervals. 

Urethral  discharge  of  muco-pus  occasionally  occurs  in  enlarged  pros- 
tate. This  is  due  either  to  mechanic  pressure  on  the  organ  during  stool 
or  micturition,  or  to  co-existing  anterior  urethritis.  In  long-standing  cases 
there  may  be  urethral  hemorrhage  from  time  to  time  as  a  consequence  of 
prostatic  congestion.  These  cases  are  less  liable  to  acute  retention  because 
of  the  conservative  effect  of  the  bleeding. 

As  the  morbid  changes  increase,  the  patient  becomes  very  irritable  and 
testy;  slight  chilly  sensations  and  more  or  less  fever,  particularly  during 
the  afternoon,  are  not  unusual.     The  functions  of  the  digestive  organs  are 


704 


HTPEETEOPHY    OF    THE    PEOSTATE. 


apt  to  be  more  or  less  disturbed;  the  general  strength  is  somewhat  im- 
paired, sometimes  early  in  the  case.  These  various  symptoms  are  due  to 
more  or  less  impairment  of  renal  function,  with  consequent  slight  uremia, 
in  combination  with  a  certain  degree  of  absorption  of  the  products  of  de- 
composition— toxins — from  the  urinary  tract.  This  condition  may  be 
termed  chronic  urinary  fever. 

In  the  early  stages  of  enlarged  prostate  the  urine  contains  more  or 
less  mucus;  later  on  this  is  replaced  by  muco-pus,  in  the  form  of  gouts  and 
clots,  and  an  abundance  of  triple  phosphates.  Sometimes  the  fluid  is  dark 
from  admixture  with  blood,  particularly  if  calculus  exists.  The  acidity  of 
the  urine  gradually  diminishes  until  it  eventuall}"  becomes  ammoniacal  and 
fetid. 

If  calculus  forms  there  may  be  considerable  pain,  particularly  during 
movements  involving  jolting  of  the  body.  This  pain  is  not  so  marked,  as 
a  rule,  as  in  calculus  from  other  causes.  In  ordinary  cases  of  stone  the 
stream  of  urine  during  micturition  is  apt  to  be  suddenly  checked,  and  coin- 
cidently  severe  pain,  with  more  or  less  bleeding,   occurs  during  the  ex- 


Fig.  137. — Small  phosphatic  calculi  (secondaiy)  removed  from  three  pros- 
tatiques.  The  vesical  pain  in  these  cases  was  excruciating.  (Author's 
cases.) 


pulsion  of  the  last  few  drops  of  urine.  In  enlargement  of  the  prostate  the 
stone  usually  lies  passively  behind  the  obstruction  at  the  vesical  neck,  and, 
the  contractility  of  the  bladder  at  the  has-fond  being  practically  nil,  it  is 
not  impelled  against  the  prostato-vesical  orifice  at  the  termination  of  mic- 
turition. The  author  has  met  with  marked  exceptions  to  this  rule,  how- 
ever, in  which  small  calculi  caused  severe  pain. 

Attacks  of  acute  cystitis  may  intervene  in  the  course  of  hypertrophy 
of  the  prostate,  and  may  result  fatally  through  systemic  exhaustion,  per- 
haps from  gangrene  of  the  vesical  mucosa.  Gouty  or  rheumatic  patients 
are  especially  liable  to  intercurrent  retention  and  acute  inflammation. 

x4s  the  foregoing  symptomatology  demonstrates,  there  is  no  class  of 
patients  more  worthy  of  the  sympathy  and  careful  attention  of  the  phy- 
sician than  the  unfortunate  victims  of  pronounced  prostatic  hypertrophy. 
It  is  sad  that  a  large  proportion  of  humanity  should  be  afiiicted  with  so 
harassing  an  infirmity  during  the  declining  years  of  life,  when  there  are 
so  manv  other  senile  infirmities  to  make  life  uncomfortable.     As  a  conse- 


DIAGNOSIS    OF   HYPEKTEOPHY    OF    THE    PEOSTATE.  705 

quence  of  the  drain  upon  the  system  produced  by  the  discharge  of  pus  from 
the  bladder,  and  depression  of  the  nervous  system  from  pain  and  loss  of 
sleep  in  combination  with  the  general  effects  of  senility,  the  patient  with 
enlarged  prostate  is  apt  to  have  his  life  considerably  shortened,  even  though 
he  escape  the  dangers  of  acute  retention,  cystitis,  and  renal  complications. 
The  fact  that  the  life  of  the  patient  will  inevitably  be  made  miserable  is 
sufficient  to  warrant  us  in  seeking  radical  measures  of  relief  and  adopting 
them  early,  when  operation  is  comparatively  safe  and  holds  out  a  reason- 
able prospect  for  permanent  benefit. 

Diagnosis. — The  most  accurate  information  regarding  the  condition 
of  the  prostate  is  to  be  obtained  by  rectal  exploration  with  the  finger.  The 
bowels  should  be  evacuated  by  means  of  an  enema,  and  if  the  patient  is 
very  sensitive  a  small  quantity  of  morphia  or  cocain  may  be  introduced  by 
suppository  a  short  time  previous  to  the  examination.  The  prostate  is  dis- 
cernible to  the  expert  finger  even  in  its  normal  condition;  but  whenever  it 
is  at  all  prominent  some  condition  of  disease  may  be  inferred.  In  certain 
cases  of  enormous  enlargement  of  the  organ  the  rectum  is  so  encroached 
upon  that  the  tumor  can  be  felt  immediately  the  finger  passes  the  sphinc- 
ter, making  exploration  somewhat  difficult.  By  this  digital  exploration  the 
size  and  conformation  of  the  prostate  are  readily  determined.  When  poste- 
rior median  enlargement  exists,  a  certain  degree  of  resistant  fullness 
will  be  detected  above  the  upper  border  of  the  organ  where,  when  the  pros- 
tate is  normal,  nothing  can  be  felt  save  the  elastic  fluctuating  wall  of  the 
bladder.  It  is  desirable  to  note  whether  the  bladder  is  accessible  beyond 
the  border  of  the  prostate  as  evidenced  by  marked  fluctuation,  especially 
if  there  is  a  possible  necessity  of  tapping  the  bladder  through  the  rectum. 
If  there  is  much  inflammation  or  acute  hyperemia,  the  flnger  elicits  great 
tenderness,  with  rectal  and  vesical  tenesmus.  x\ny  irregularities  of  the  pros- 
tate that  may  possibly  indicate  tumorous  outgrowths  should  be  carefully 
outlined  and  noted. 

Great  assistance  in  exploration  is  afforded  by  a  metallic  catheter  intro- 
duced into  the  bladder.  The  instrument  and  the  exploring  finger  in  the 
rectum  are  made  to  engage  between  them  the  structures  about  the  vesical 
neck.  An  approximate  idea  of  the  extent  of  the  hypertrophy  and  the  de- 
gree of  induration  may  thus  be  formed.  By  urethral  exploration  we  may 
often  derive  considerable  information  regarding  the  condition  of  the  pros- 
tate. In  a  suspected  case  of  hypertrophy  the  first  attempt  at  exploration 
should  be  made  with  an  ordinary  catheter.  If  this  passes  readily  without 
the  necessity  of  marked  depression  of  its  handle,  and  if,  moreover,  urine 
fiows  through  it  when  it  has  penetrated  to  the  depth  of  seven  or  eight 
inches,  the  prostate  is,  in  all  probability,  not  appreciably  enlarged.  If  hy- 
pertrophy exists  it  will  be  necessary  to  depress  the  handle  of  the  catheter 
well  down  toward  the  patient's  feet  before  its  point  will  enter  the  bladder, 
and  even  then  it  may  be  found  impossible  to  introduce  it  without  undue 


706 


HYPEETEOPHY    OP   THE    PEOSTATE. 


force^  because  of  the  point's  impinging  upon  a  bar  at  the  vesical  neck 
or  the  median  lobe,  as  the  case  ma}'  be.  Urine  does  not  flow  until  the  in- 
strument has  penetrated  to  a  depth  of  perhaps  ten  inches  or  more.  If  the 
ordinary  catheter  does  not  pass  readily,  Thompson's  metallic  prostatic 
catheter,  which  has  a  longer  and  more  pronounced  curve,  should  be  em- 
ployed. This  instrument  will  usually  pass  by  a  median  hypertrophy  or 
bar  with  comparative  ease.  When  the  lateral  lobes  are  asymmetrically 
enlarged  the  point  of  the  catheter,  and  consequently  the  handle,  is  de- 
flected in  a  direction  corresponding  to  the  existing  malformation  of  the 
urethra.  The  depth  to  which  it  is  necessary  to  pass  an  instrument  before 
the  urine  flows  is  a  fair  criterion  of  the  degree  of  enlargement.  Thompson 
has  devised  a  "searcher"  for  exploration  of  the  bladder,  which  in  practical 
hands  gives  very  valuable  information  regarding  the  size  and  form  of  pro- 
static hypertrophy,  the  presence  of  tumor  or  stone,  and  the  depth  of  the 
las-fond. 


Fig.  138. — Exploring  sound  for  diagnosing  condition  of  vesical  neck, 
method  of  outlining  enlarged  prostate. 


ShoAving 


It  is  usually  best  to  examine  the  patient  in  the  dorsal  decubitus  with 
knees  and  thighs  flexed  and  separated.  In  rectal  examination  of  the  pros- 
tate, however,  a  position  similar  to  Sims's  is  preferable. 

DiFEEEENTiAL  DIAGNOSIS. — This  requires  the  exclusion  of  stricture, 
vesical  calculus,  vesical  tumors,  atony,  paralysis,  and  simple  catarrh  of  the 
bladder,  stricture  and  vesical  calculus  being  the  diseases  for  which  hyper- 
trophy of  the  prostate  is  most  likely  to  be  mistaken.  Most  of  these  con- 
ditions may  usually  be  excluded  by  careful  study  of  the  history,  and  phys- 
ical examination  to  determine  the  size  and  form  of  the  prostate  and  the 
length  and  contour  of  the  urethra.  The  age  of  the  patient  is  always  a 
most  important'  consideration. 

It  is  wise  not  to  be  too  arbitrary  in  the  matter  of  diagnosis  based  upon 
subjective  s^nnptoms,.  as  the  various  diseases  mentioned  have  many  S3rmp- 
toms  in  common.     Calculus  often  co-exists  with  enlarged  prostate  and  is 


TEEATMENT    OP   HYPERTEOPHT    OF    THE    PEOSTATE.  707 

unsuspected  because,  as  already  stated,  vesical  contractility  is  so  impaired 
that  the  stone  cannot  be  forced  against  the  tender  vesical  neck.  Rectal  ex- 
ploration with  the  finger  and  vesical  exploration  by  instruments  are  always 
necessary  to  complete  the  diagnosis. 

Teeatment.  —  Palliative  and  Prophylactic  Measures.  ■ —  It  is  obvious 
that  in  quite  a  proportion  of  cases  of  prostatic  hypertrophy  the  treatment 
must  devolve  upon  the  general  practitioner  and  should  consist  of  measures 
of  palliation.  The  author  desires  to  impress  upon  the  general  practitioner, 
however,  the  fact  that  the  cases  in  which  palliative  measures  should  be 
selected  and  relied  upon  throughout  are  only  to  be  determined  by  careful 
study.  Palliative  treatment,  as  a  matter  of  routine,  should  no  longer  be 
accepted  as  the  inevitable  in  prostatic  hypertrophy,  excepting  under  cir- 
cumstances in  which  it  is  impracticable  to  place  the  patient  under  suitable 
conditions  or  in  proper  hands  for  operative  measures.  Palliative  measures 
of  treatment  necessarily  have  a  more  important  practical  interest  to  the 
general  practitioner  than  to  the  genito-urinary  specialist.  The  function  of 
the  latter  is  often  that  of  a  consultant  only,  the  management  of  the  case,. 
if  operative  measures  are  not  advocated,  being  subsequently  relegated  to 
the  family  practitioner.  Comparatively  few  diseases  of  such  prolonged  dura- 
tion as  enlarged  prostate  remain  throughout  under  the  care  of  the  surgical 
specialist. 

It  is  to  be  remembered  that  the  primary  source  of  discomfort  in  in- 
cipient cases  is  irritation  of  the  vesical  neck  incident  to  hyperemia  and 
resulting  hyperplasia  of  the  prostate  and  its  environs.  Hyperacidity  of  the 
urine  and  the  gouty  or  rheumatic  diathesis  are  also  likely  to  exist.  Proper 
measures  of  treatment  to  correct  the  diathetic  condition  and  remedies  that 
lessen  the  irritating  properties  of  the  urine  are  always  of  service.  An- 
aphrodisiacs  are  also  frequently  beneficial.  The  remedies  that  have  proved 
most  serviceable  in  allaying  vesical  irritability  are  buchu,  triticum  repens, 
pichi,  saw  palmetto,  sandal-wood  oil,  capaiva,  ustilago  maydis,  eucalyptus, 
uva  ursi,  ulmus,  and  some  others  of  a  similar  character.  No  one  of  these 
various  remedies  can  be  said  to  be  equally  satisfactory  in  all  cases.  It  is 
very  often  necessary  to  do  considerable  experimenting  to  determine  which 
remedy  is  most  efficacious  in  a  particular  case.  Bromid  of  potassium,  and 
ergot  in  full  doses  combined  with  gelsemium,  have  seemed  to  be  of  especial 
value  in  the  author's  experience.  This  combination  not  only  has  a  special 
effect  upon  the  involuntary  fiber  and  vascular  supply  of  the  prostate,  but  also 
a  special  action  upon  the  hyperactivity  of  the  sexual  function,  which  prob- 
ably has  much  to  do  with  the  causation  of  many  cases.  The  occasional  pas- 
sage of  the'  sound  or  catheter,  usually  advised  even  in  incipient  cases  for 
the  purpose  of  withdrawing  residual  urine,  is  beneficial.  In  incipient  cases, 
however,  the  benefit  is  derived,  not  from  the  withdrawal  of  residual  urine 
which,  if  it  be  not  infected,  has  little  or  no  influence  upon  the  irritation, 
but  from  allaying  hyperesthesia  of  the  prostatic  urethra. 


708 


HYPEETEOPHT    OF   THE    PEOSTATE. 


The  general  treatment  is  of  great  importance  in  all  cases  of  prostatic 
hypertrophy.  Temperate  habits  and  dietetic  abstemiousness  are  essential. 
If  the  gouty  or  rheumatic  diathesis  exists  the  usual  preparations  of  col- 
chicum,  lithia,  and  the  salicjdates  are  indicated.  Alkaline  diluents,  min- 
eral waterS;,  or  pure  distilled  water  in  large  quantity  are  of  service  in  ren- 
dering the  urine  bland  and  unirritating.  Certain  remedies  have  an  excel- 
lent effect  in  preventing  or  correcting  decomposition  of  the  urine,  by  their 
inhibiting  or  destructive  effect  upon  the  bacteria  which  bear  so  impor- 
tant a  relation  to  secondary  chronic  cystitis  in  advanced  cases  of  prostatic 


Fig.   139. — Olive-tipped  flexible  catheter. 

hypertroiDhy.  The  best  remedy  is  oil  of  eucal3^ptus  in  doses  of  10  minims, 
combined  with  10  grains  of  salol,  given  four  times  daily,  preferably  after 
meals  and  at  bed-time.  Boric  acid  and  salol  alone  have  been  disappointing. 
Benzoate  of  soda,  naphthol,  guaiacol,  and  small  doses  of  carbolic  acid  are 
sometimes  beneficial.  Cystogen  is  a  new  and  highly  extolled  remedy.  The 
remedies  previously  mentioned  as  having  a  special  effect  upon  the  vesical 
mucosa  are  especially  indicated  where  cystitis  exists. 

Eegarding  urinary  antisepsis,  Professor  Wesener,  of  the  Chicago  College 
of  Physicians  and  Surgeons,  conducted,  at  the  author's  suggestion,  a  series 


Fig.   140. — Jacque's  soft  catheter. 


of  experiments  with  various  drugs.  His  results  substantiated  the  author's 
opinion  of  the  efficacy  of  eucalyptus,  but,  strange  to  say,  he  found  lactic 
acid  to  be  more  actively  antiseptic  than  anything  that  was  tried.  Lactic 
acid  in  what  might  be  termed  its  latent  form  in  sour  milk  is  most  efficacious. 
Exercise  in  moderation  is  to  be  recommended  for  prostatiques.  Horse- 
back-riding, bicycling,  and  all  exercises  involving  jolting  movements  of  the 
body  or  pressure  on  the  perineum  should  be  avoided,  especially  if  a  com- 
plicating calculus  exists.  Exposure,  particularly  such  as  involves  chilling 
of  the  feet  and  legs,  is  apt  to  bring  on  acute  retention  of  urine.     "Warm 


TEEATMEXT    OF    HYPEKTEOPHY    OF    THE    PEOSTATE.  709 

■underclotliing  and  protection  from  exposure  to  the  weather  should  there- 
fore be  insisted  upon. 

In  advanced  cases  it  is  to  be  remembered  that  the  principal  source  of 
discomfort  consists  in  the  presence  of  decomposing  residual  urine  in  the 
ias-fond.  The  resulting  frequency  of  urination  necessarily  enhances  the 
irritation  and  inflammation  of  the  parts  about  the  vesical  neck.  The  first 
indication,  therefore,  is  to  prevent  retention  and  decomposition  of  residual 
urine.  Inasmuch  as  the  patient  finds  it  impossible  to  empty  the  bladder, 
it  is  necessary  to  supplement  the  normal  function  of  micturition  by  complete 


Fig.  141. — The  catheter  coude. 


evacuation  of  the  viscus  via  the  catheter.  At  a  comparatively  early  period 
of  the  disease  a  single  complete  evacuation  of  the  bladder  daily  is  often  suffi- 
cient to  prevent  serious  discomfort  for  an  indefinite  time.  When  the  pa- 
tient can  afford  the  necessary  time  and  expense  it  is  best  that  this  be  done 
by  the  physician. 

When  it  is  practicable  for  the  patient  to  evacuate  his  own  bladder  with 
the  catheter,  a  suitable  instrument  should  be  selected  for  him.  The  only 
instrument  with  which  the  average  patient  should  be  intrusted  is  some  one 
of  the  many  forms  of  soft  catheter.    The  best  of  these  is  the  Jacques  cathe- 


Fig.  142. — Metallic  catheter  with  pi'ostatic  cun-e. 

ter,  a  soft  and  perfectly-flexible  rubber  affair,  with  which  the  patient  can- 
not possibly  injure  himself. 

In  some  instances  this  catheter  is  too  flexible  and  it  is  necessary  to 
substitute  some  other  variety.  There  is  a  form  of  more  substantial  con- 
sistency known  as  the  silk  catheter,  and  another  equally  serviceable,  the 
foundation  of  which  is  Belfast  linen.  The  author  prefers  the  latter  to  any 
other,  especially  as  they  may  also  be  intrusted  to  the  patient.  When  there 
is  pronounced  obstruction  at  the  vesical  neck,  such  as  arises  from  the 
existence  of  marked  median  hypertrophy  or  bar,  Mercier's  catheter  coude, 
also  a  soft  instrument,  the  end  of  which  is  permanently  bent  at  a  slight 


710 


HTPEETEOPHT    OF    THE    PEOSTATE. 


angle  or  elbow,  will  be  found  more  serviceable  than  the  ordinary  flexible 
varieties.  The  elbow  at  the  end  of  the  instrument  serves  to  direct  the  point 
up  over  any  barrier  that  opposes  its  passage  into  the  bladder.  In  some  in- 
stances the  ordinary  old-style  English  catheter  with  the  stylet  will  be  found 
most  useful  to  the  surgeon,  if  certain  little  details  in  its  manipulation  are 
observed.  Care  should  be  taken  to  keep  the  catheters  scrupulously  clean; 
they  should  be  washed  out  with  a  5-per-cent.  solution  of  carbolic  acid  every 
time  they  are  used,  and  when  introduced  should  be  smeared  with  bichlorid 
of  mercury  and  liquid  vaselin  1  to  3000,  a  little  cocain  being  added  to  the 
ointment  if  the  urethra  and  neck  of  the  bladder  be  intolerant  of  instruments. 
In  advanced  cases  it  is  desirable  that  the  bladder  be  evacuated  three  or  four 
times  in  the  course  of  the  twenty-four  hours.  In  some  instances  it  is 
best  for  the  patient  to  depend  entirely  upon  the  catheter  for  the  evacua- 
tion of  his  urine.  The  bladder  should  be  washed  out  daily  (and  in  severe 
cases  several  times  daily)  with  a  warm  antiseptic  solution.  Bichlorid  of 
mercury,  1  to  20,000;  carbolic  acid,  in  V2"P6r-cent.  solution;  or  a  satu- 
rated solution  of  boric  acid  are  all  useful  for  this  purpose. 


Fig.  143. — Catheter  coitdv  with  prostatic  curve. 


The  following  combination  is  of  service: — 

IJ  Sodii  biborat Bij. 

Ac.  carbol §ij . 

Glycerini  q.  s.  ad  Bviij. 

M.     Sig. :    §ss  in  a  quart  of  warm  water  as  an  irrigating  lotion,  ]).  r.  n. 

The  lotion  should  be  moderately  warm,  or,  if  it  seems  desirable,  as  hot 
as  can  be  borne.  In  lieu  of  a  glass  irrigator  there  is  no  better  apparatus  for 
irrigation  than  an  ordinary  fountain-syringe  with  or  without  a  soft  catheter. 
The  fluid  should  be  allowed  to  enter  the  bladder  in  small  quantity  at  a  time, 
for,  if  the  inflamed  bladder  be  distended  greatly,  an  increase  of  irritation 
will  result,  and  perhaps  pain  will  be  produced  by  the  operation.  After  each 
irrigation  it  is  advisable  to  leave  a  couple  of  ounces  of  fluid  in  the  bladder. 
When  cystitis  is  severe  the  daily  prolonged  use  of  the  hot  sitz-bath,  prefer- 
ably on  retiring  for  the  night,  is  of  service.  Further  expatiation  upon  the 
treatment  of  complicating  cystitis  is  hardly  necessary,  as  it  will  receive  full 
consideration  in  the  chapter  on  diseases  of  the  bladder. 


TEEATMENT    OP   HYPEETKOPHT    OF   THE    PEOSTATE.  711 

Should  retention  of  urine  develop,  it  should  be  relieved  as  quickly  as 
possible,  for  typhoid  symptoms  are  apt  to  supervene  very  rapidly  in  these 
elderly  and  debilitated  patients.  Morphia  in  small  doses  and  the  general 
hot  bath  will  facilitate  surgical  measures  for  the  relief  of  retention.  A 
soft  catheter  should  be  passed  if  possible,  and,  failing  in  this,  the  ordinary 
gum  catheter  with  a  stylet  may  be  used.  The  stylet  should  be  curved  to 
conform  with  the  prostatic  urethra,  and  care  should  be  taken  not  to  esert 
much  force  upon  the  catheter  in  its  introduction,  as  the  point  will  very 
often  catch  at  the  point  of  obstruction.  Under  such  circumstances  the  in- 
strument may  often  be  successfully  passed  by  pressing  against  it,  just  below 
its  point,  by  the  index  finger  introduced  into  the  rectum.  The  finger  in 
this  instance  acts  as  a  fulcrum,  and  the  force  employed  in  passing  the 
catheter  is  expended  against  it  instead  of  the  prostatic  obstruction  or  bar. 
This  little  maneuver  will  often  succeed  where  the  introduction  of  an  in- 
strument would  otherwise  be  impossible.  "  It  will  be  found  that  with  this 
semiflexible  instrument  the  pressure  of  the  finger  just  in  front  of  the  anus 
will  often  answer  the  same  purpose,  the  handle  of  the  catheter  being  de- 
pressed simultaneously  with  the  application  of  pressure  to  the  portion  oc- 
cupying the  deep  urethra.  It  will  be  seen  that  in  maneuvers  of  this  kind 
an  accurate  knowledge  of  the  conformation  of  the  distorted  urethra  is  re- 
quired. There  is  no  danger  in  employing  tolerably  firm  pressure  after  the 
surgeon  becomes  moderately  expert  in  this  method  of  procedure,  providing 
such  pressure  be  received  upon  the  finger  applied  to  the  bend  of  the  catheter 
in  the  perineum. 

Another  little  maneuver  that  will  be  found  to  be  very  ef&cacious  is 
the  following:  The  stylet,  having  been  given  an  exaggerated  curve,  is 
passed  into  the  catheter,  and  the  latter  introduced  into  the  urethra  until 
it  comes  in  contact  with  the  obstruction;  the  point  is  now  pressed  with  mod- 
erate firmness  against  the  obstruction,  with  the  fingers  of  the  left  hand 
upon  the  handle,  and  the  stylet  is  withdrawn,  while  the  catheter  is  pushed 
steadily  forward.  It  will  be  found  that,  as  a  rule,  the  withdrawal  of  the 
stylet  will  curl  the  point  of  the  catheter  upward  and  forward,  in  such  a 
manner  that  the  point  of  the  instrument  readily  glides  snakewise  upward 
over  the  obstruction  and  into  the  bladder. 

When  it  is  found  to  be  impossible  to  introduce  a  flexible  or  semiflexible 
instrument,  Thompson's  silver  or  the  Gross  jointed  metallic  catheter  may 
be  used.  In  extreme  cases  it  may  be  found  necessary  to  aspirate  or,  in 
lieu  of  an  aspirator,  to  use  a  small  trocar.  Dieulafoy's  aspirator  is  the  best 
for  the  purpose.  The  operation  of  tapping  may  be  repeated  a  number  of 
times  if  necessary  while  waiting  for  the  acute  congestion  of  the  parts  about 
the  neck  of  the  bladder  to  subside,  after  which  the  urine  either  flows  readily 
or  may  be  evacuated  by  the  catheter.  Should  a  trocar  be  used  in  lieu  of  the 
aspirator,  it  may  be  passed  into  the  bladder  above  the  pubes  or  through  the 
rectum.    In  the  latter  event  a  very  small  curved  instrument  should  be  used. 


712 


HYPEETEOPHY    OF   THE    PEOSTATE. 


the  bladder  being  punctured  in  the  trigonum  vesicce  just  above  the  border 
of  the  prostate.  Should  median  hypertrophy  exist  and  fluctuation  at  this 
point  be  absent,  rectal  puncture  will  be  impracticable.  When  the  trocar 
is  used,  it  is  necessary  to  leave  the  cannula  in  situ  until  it  becomes  prac- 
ticable to  evacuate  the  bladder  by  means  of  the  catheter. 

If  retention  has  existed  for  some  little  time,  care  should  be  taken  not 
to  evacuate  the  bladder  completely,  lest  there  be  set  up — as  a  consequence 
of  removal  of  pressure  from,  and  acute  infection  of,  the  already  weakened 
A^esical  walls — acute  inflammation  and  sloughing,  with  an  inevitably  fatal 
result.  It  has  been  shown  experimentally  that  this  is  due  to  acute  bacterial 
infection,  the  resistance  of  the  tissues  having  been  lessened  by  the  circula- 
tory disturbance.    Such  accidents  are  not  so  rare  as  might  be  supposed. 

In  a  day  or  two,  after  the  bladder  has  contracted  down  somewhat,  it 
is  safe  and  advisable  to  evacuate  it  completely  at  each  seance.    The  author 


Fig.   144. — Routes  for  vesical  puncture. 

has  in  some  instances  completely  emptied  the  bladder  at  once,  following  its 
evacuation  by  irrigation  with  a  warm,  mild,  antiseptic  solution  and  leaving 
a  sufficient  quantity  of  the  irrigating  fluid  in  the  bladder  to  moderately  dis- 
tend its  walls. 

It  will  be  found  that  very  few  cases  will  require  aspiration  if  the  cathe- 
ter be  intelligently  used. 

It  should  be  remembered,  in  connection  with  the  subject  of  retention, 
that  after  a  time  the  urine  is  likely  to  dribble  away  as  a  consequence  of  over- 
flow. This  may  mislead  the  practitioner  into  the  belief  that  there  is  no 
longer  any  necessity  for  evacuation  of  the  bladder.  Many  an  old  man  has 
been  allowed  to  die  unrelieved  because  of  the  ignorance  of  his  physician  on 
this  point. 

A  very  useful  maneuver  in  the  palliative  treatment  of  prostatic  disease 
is  the  knee-chest  posture.  If  the  patient  will  assume  this  posture  and  main- 
tain it  as  long  as  consistent  with  comfort,  several  times  daily,  while  the 


TEEATMENT    OF   HYPERTKOPHY    OF    THE    PEOSTATE.  713 

bladder  contains  a  moderate  amount  of  urine,  the  las-fond  will  be  drained 
into  the  body  of  the  bladder,  and  the  stagnant,  infected  residual  urine  re- 
placed by  comparatively  healthy  urine  freshly  entering  the  bladder.  If 
catheterization  and  irrigation  be  added  to  the  knee-chest  posture  the  blad- 
der can  be  cleansed  and  drained  in  a  much  more  thorough  manner  than  by 
any  other  method.  Another  good  plan  is  to  have  the  patient  urinate  in  the 
prone  position.  This  can  be  accomplished  by  lying  across  chairs,  or  upon 
a  long  bench  provided. with  a  suitable  hole  for  urination. 

Radical  Treatment. — Until  recently  the  treatment  of  hypertrophy  of 
the  prostate  consisted  only  of  palliation.  Internal  medication  and  treat- 
ment by  pressure  in  the  hope  of  absorbing  the  adventitious  tissue  composing 
the  overgrowth  had  alike  proved  ineffectual.  Eadical  surgical  measures 
were  considered  inapplicable.  With  a  large  percentage  of  the  profession 
this  view  holds  at  the  present  day.  In  the  light  of  the  development  of  mod- 
ern aseptic  surger}^,  however,  particularly  in  the  direction  of  operations 
upon  the  genito-urinary  tract,  this  old-time  notion  should  be  abandoned. 
The  author  has  no  desire  to  foster  a  spirit  of  surgical  hyperactivity,  but  he 
is  firmly  convinced  that  there  is  a  wide  field  for  judicious  operative  meas- 
ures in  hypertrophy  of  the  prostate.  Eadical  measures  are,  of  course,  not 
applicable  to  all  cases;  the  results  of  operations  by  surgical  routinists  are 
unworthy  of  consideration.  In  certain  quarters  it  is  held  that  surgical  in- 
tervention is  not  to  be  thought  of  until  the  patient  is  in  such  a  desperately 
bad  condition  that  operative  measures  afford  very  little  prospect  of  success. 
The  surgery  of  the  prostate  has  never  been  given  a  fair  opportunity  for 
development.  The  cases  submitted  to  us  for  operation  are  usually  those 
in  which,  not  only  have  all  other  measures  of  treatment  failed,  but  com- 
plicating conditions  have  arisen  that  seriously  enhance  the  dangers  of  op- 
eration. Operative  statistics  based  upon  the  results  obtained  in  the  class 
of  patients  upon  whom  we  at  present  have  the  most  frequent  opportunities 
of  operating  are  practically  worthless,  excepting  in  so  far  as  they  bear 
u]3on  a  radical  cure  or  recovery  from  the  operaijion  in  a  particular  class  of 
desperate  cases.  With  a  proper  understanding  of  the  limitations  and  in- 
dications of  the  operation  and  a  Judicious  selection  of  cases  there  is  no 
reason  why  early  operations  upon  the  prostate  should  not  5deld  excellent  re- 
sults. In  the  opinion  of  the  author,  radical  operations  upon  the  prostate 
should  be  comparatively  safe  if  performed  prior  to  the  development  of  sep- 
tic complications  or  renal  disease:  i.e.,  if  performed  at  a  comparatively  early 
period  after  the  development  of  urinary  obstruction.  A  fairly  good  pros- 
pect of  success,  sufficiently  good  to  warrant  operative  interference,  exists 
even  after  vesical  complications  have  developed,  providing  the  kidneys  have 
retained  their  structural  and  functional  integrity.  Inasmuch  as  mechanic 
obstruction  and  sepsis  develop  serious  vesical  and  renal  conditions  sooner 
or  later  in  by  far  the  majority  of  prostatiques,  it  is  evident  that  operations 
should  be  done  much  earlier  than  they  usually  are. 


7_i     -   -    -             _i  iL  T 1     :  ^    '  - : :  t£Jt  MSrsnssa  age  trujd.  cffiwpgri- 
A^iaseei.  cases  is  pEnsns  of  -Otfeeawase  Tnggrwi  bodxji  _^  "j^jim 
SHTL'i'TiiJT  lBi'i*<i^Tg43.  liEt  in  T"^    _    ■_::-    ^-  iirr>rT^EiTE  TOEreBSr    .:    — : 

nf  J  ASTTEneec  saset  in  Terr  lui  s^i^ie^^s  "B"Ji£if  scn   ..r  z^^L-  i^i  :_ii- 
Sht-   '-'iriiSiaaiJiifi  cesi.  inn  palliaxixs  -mfiaFiirg  fiTt  =~: : :  — :Tv^ 

AriT^EiiDefi  eases  irr^eenx^  m  Jtge  ia  ^wioeb.  r  —  .   i 

^-^.=r.  ion  pt)T!^ i.it-^  nHafamnee  are  iwrSfsg, 

,  f )  Cas^  nm  i-HTi  49M  ip^*^  is  v^oaa  wriial  pow^r  i£  Iqbi- 

(-1  C^^  efiHUf^caSiBi  Irv'  T^£al  fiaTffalnf.. 

laa  Ois  «  v«E  imve  to  deal  Mjjji  hieb  M  <as  aboFe  ^a^*^^  age  im 

fiCBUi^  faimatnp  «£  ^^  sffiG^  SMnd  3Banr  aBaT  Ae  iniialsalitj  of  iiie  ineaesd 
^£1^  ani.  csi^eT  gisad^  Keaasd  ds  Js^pEstsfo^bae  pveees  <»  piatiiiically  pve- 

-vssaiiL.    TSiese foiSaaise saenane ai€ staBedanes SQ  agBalbr  saeees^Bl  Aat 

«|BeBaEl3iffi  S  IkHi  19  ^  tSura^tf  «£.    Wlaanp  mBaiM*M!iiii  Jul.  ImmppctTj,  or  if.  after 

imiinnirrffilT  TTiriTrnnfiBl  fmlfriitiTim  feg  flsaae  mwnri^  <g  ireaas.  imsaij  olielbrae- 
^acea  aad  :^2Q^iBeHi  ioesease  ^ss  a«*fii^  '^  iteSestiGB  eone  ob.  an^ieal  laler- 
leBeaiffie  is  pBOSaMs  and  sbsraM  ^  petismei  he^ast  sesmos  ^^eEKal  and 
wiiuil  imwitfiTMjnT>inii  \mr  JIhim  iw  deveis^  angL  vMle  tibe  emsiitaiian  of  the 

•yap  pgt:W»«aGc  j^BTtnawa  ia  Oaas  i  «y  iMiNirainy  i1>p  legTJaBMte  safiBeSBOg 

fii  CSuE  A.    TSas  aoQf  iB^ei^asiK  &r  opooiaaa.  pane'iaiL 

C^^  «  tfusmrjirmpf  -^  casEE  jwr  gngflBBoe  ja  vfia^  moAmg  \mi  paHia- 

Saos  KiGBsaesE  ^asoaM  Be  t^otadesied.  Tbef  fimwfrrwp  ^pdie  a  funfiutlifla  of 
eme^  ^bS,  -vnbi^  in  seiBs  <^  liwaw  ^peaaaMs.  »»i»i«*^  bav^  beia  pnfified  at 
as  eas^  pesasti.  m  eoiamlT  5s  1101  so  ai  a  m^ate  adhtaaeeS  ^ckid  <i^  Hfe  bo 

lone  ihs  'Scdjt  i^csxpe  of  -ps^m^msm.  oi  1if«p  aaid  i^isl  <jd  sttb^^&o^    The 

^baaawapff  ije  •a^^gysorkm  m  ts  Ix  ■d?:=r7rznei  Igt^lr  Vr  Til?  '':-?.   T-rr'^t:?!!? 

ClbK  *  s  :3»  55fia1  ^^c^  m  eass  in  -aia^  €:  ;  ^     1:  - 

TThp  wuBorm&ix  m  b©  Iott,  asd  l3i£  TtiJij-TVpon  inadest  t  '  i? 

«a  aadi  issTml  inrpOTiaiiss.  T^tat  -^^s^  tarn,  fee  -psatsts^sUr  -  - 


TBEATMES'T    OF  HYPEETSOPHT  OF  THE  PKOeiATE.  T15 

gonangiectomy^ — ^maT  be  proposed  as  a  eoiapreiniise  in  ease  uhe  patieiit  ab- 
jeeta  to  castration-  and  is  effective  in  a  eertarn  pTf^xtifia  of  eases- 

In  Class  /  there  is.  in  the  anth-ors  ■  jne  indicatifjn-  viz.: 

suprapiibie  section,  with,  or  withoiit  opera* __  -^, :_  :_-  prosca^e  proper,  and 
prolonged  drainage.  Tlie  question  of  operation  upon:  these  patiems  k  de- 
cided by  the  esistenee  of  calculus,  bnt  modified  hj  zhe  same  eonsidefSifeHHSs 
regarding  complications  and  tKe  strength,  of  the  patient  as  in  eases  rn  ifimA 
it  i&  absent.  It  is  tme  that  brilliant  resnlts  bave  been  reported  from  tJie- 
operation  of  litholapa^y  in.  prostatiques.  It  neTertbeless  seems  to  tbe  axcEb-or 
less  rational  and  more  dangerous,  irpon  the  aTerage.  than,  snprapithie  sectfon 
and  drainage,  especiallj  if  th.e  operation  be  done  in  rwo  stages. 

The  operations  indicated  in.  prostatic  brpertrGpiij  range  in  sererniT 
from  sfmple  Tasectomy  to  remoTal  of  xh&  brpennropliie  trseoe.  seledion.  of 
operation  being  dependent  npon  th.e  Tarfetr  of  bypernropliy.  the  ecudftion. 
of  the  bladder  and  Mdneys,  and  th.e  degcee  to  which,  tbjg  patienf  s  strengti. 
has  been  tindermined.  In  qmxe  a  proportion  of  advanced  eases  only  go- 
nangieetomy  is  warrantable  as  a  primary  attempt  to  rdiere.  This  faflfrtg, 
snprapnbic  section  and  drainage  axe  alone  to  be  eon  sf dared-  ETen  thfs 
procedure  may  be  imwarrantable  on  acconnt  of  serians  eom.plieatioFff-  A 
permanent  artificial  snprapiibic  nretbra  is  th.e  only  me^fsre  of  rgflef  fer 
tkese  advanced  cases,  but  excellent  judgment  m  often  necessary  to  detsmine 
whether  the  patient  is  likiely  to  enditre  operation.  The  operation,  shanld  be 
performed  in  two  stages,  and  in  a  general  way  chloroform  sh-OtEld  be  used  if  a 
general  anesthetic  be  given-  The  anesthetic  is  the  f  eatttre  ef  the  opaatioT! 
most  to  be  dreaded,  and  where  practicable  it  is  advisable  to  do  both,  tiie 
primary  and  secondary  operations  involved  in  opening-  th£  bladder  in.  two 
stages  under  a  weak  solution  of  eoeara:  Sehleiehr's  m.efehfid  is  a  good  one. 
Shonld  distinetiy  eirc-Trm  scribed  posterior  prostatic  trrmors  esist  they  shcFoM" 
be  removed.  It  is  sometimes  possible  to  remove  a  pedtEncuiated  growth. 
wiih  tile  nnger  alone.  In  advanced  easeSy  however,  it  is  adv^aMe  not 
to  perfomi  catting  or  tearing  operations  aboirt  the  vesical  neefc.  It  shonld 
be  remembered  that  in  these  cases  there  is  a  hfgh  d(^ree  of  vesical  sepsis, 
and  the  slightest  abrasion  of  Hie  mfcerifHT  qe  the  bladder  is  qiirte  a.  sshrss 
matter.  In  some  instances  it  is  advisable  to  defer  aH  operative  measores 
at  the  vesical  neck;,  either  permanently  or  TmtfT  tiie  bladder  and  goisal 
condition  of  the  patienfe  l^swe  improved  under  the  infeience  of  veseat 
drainage  and  imgation.  Sh.oiild  prostatotomy  or  prQsfeated:QTn.T.  h.o^weve£- 
be  decided  on,  throngh-and-throiigh  drainage  shonld  be  instlLided.  A 
perineal  b&utonniere  does  not  greatly  compKeate  the  aperatioa.  s  qm^j 
performed,  and  the  added  seetiriLv  afforded  th.e  patient  is  a  sumoem:  wiet- 
rant  fc'r  its  performance.    In  vonns'er  snnjects  linear  'orostatotom.'^  or  ■oros- 


-  Tie  term  STij^^ested  c~  ^-'r.   i-.    •  '•  .  -_  o?msGS.  c~ 


716  HYPEETEOPHY  OF  THE  PEOSTATE. 

tateetoni}'  with  tliroiigli-and-tlirougli  drainage  may  be  undertaken  with  a 
much  better  prospect  of  cure  than  in  the  cases  just  described. 

The  indications  for  an}^  particular  operation  upon  the  prostate  proper 
are  governed  entire!}^  by  the  variety  and  form  of  the  prostatic  hypertrophy. 

The  author  believes  that  combined  suprapubic  and  perineal  section 
often  constitutes  the  ideal  operation  for  prostatic  h3^pertrophy.  Through- 
and-through  drainage  has  manifest  advantages  in  certain  cases,  and  the 
danger  of  the  operation  is  not  greatly  enhanced  by  a  houtonniere;  then,  too, 
an}'  circumscribed  obstruction  that  exists  may  be  removed  b}''  the  most 
direct  route.  Oftentimes  conjoined  suprapubic  and  perineal  manipulation 
greatly  facilitates  prostatotomy  or  prostatectomy.  The  perineal  operation 
alone  is  often  insufficient  to  drain  the  bladder  thoroughly.  It  will  be  found, 
after  the  performance  of  the  perineal  operation  and  the  introduction  of  a 
tube,  that  suprapubic  section  of  the  bladder  will  be  followed  by  a  gush  of 
urine  mixed  with  the  pathologic  products  of  inflammation  through  the  su- 
prapubic opening  which  has  failed  to  escape  by  the  perineal  route.  If  a 
tube  be  introduced  through  the  perineum,  and  another  through  the  supra- 
pubic opening,  it  will  be  found  that  the  direction  of  least  resistance  to  drain- 
age is  above.  The  suprapubic  opening  will  not  infrequently  drain  freely 
through  and  around  the  tube,  while  not  a  drop  of  fluid  escapes  by  the  peri- 
neal route.  Flushing  of  the  bladder  through  the  suprapubic  tube  is  often 
followed  by  the  escape  of  fluid  above,  and  not  below.  Flushing  through 
the  perineal  route  is  likely  to  be  followed  by  a  similar  result.  If  the  opera- 
tion be  performed  early,  with  thorough  dilation  of  the  prostatic  ring,  fol- 
lowed by  prolonged  combined  perineal  and  suprapubic  drainage, — i.e., 
through-and-through  drainage, — by  a  large  tube,  it  is  sometimes  unnecessary 
to  do  a  cutting  operation  on  the  prostate  itself.  B}'  keeping  the  upper  end 
of  the  tube  closed — save  while  flushing  the  bladder — during  the  first  few 
days  following  the  operation  we  prevent,  in  large  measure,  the  septic  and 
irritating  effects  of  the  suprapubically  escaping  pathologic  urine. 

With  reference  to  avoiding  cutting  operations  on  the  prostate  proper, 
the  author  will  again  call  attention  to  the  fact  that  the  surgeon  is  here 
working  in  a  septic  field,  where  not  even  a  scratch  should  be  made  unless 
absolutely  necessary  for  the  removal  of  distinct  obstructions. 

Symphysiotomy  would  seem  to  offer  a  very  valuable  aid  in  some  cases 
of  prostatectomy,  especially  when  the  prevesical  peritoneal  fold  extends  low 
down  or  the  bladder  is  greath'  contracted.  The  author  is  of  opinion,  how- 
ever, that  the  results  in  operations  of  this  kind  are  not  a  fair  test  of  the 
value  of  operations  on  the  prostate  in  general.  Such  extensive  operations 
would  be  rarely  necessary  if  an  operation  were  advised  early  in  the  course 
of  the  disease  instead  of  relying  altogether  upon  the  catheter.  By  the  time 
such  extensive  pathologic  changes  have  occurred  as  require  the  major  op- 
eration on  the  prostate — i.e.,  prostatectomy — certain  conditions  have  de- 
veloped in  the  kidneys  which  frequently  defeat  the  efforts  of  the  surgeon. 


TEEATMENT    OE    HYPEKTEOPHT    OF    THE    PROSTATE.  717 

To  be  sure,  cases  present  themselves  where  even  a  combination  of  sym- 
physiotomy and  the  Trendelenburg  posture  and  cross-section  may  be  neces- 
sary. In  some  of  these  cases  the  prostate  may  be  attacked  in  this  manner 
with  great  facility  even  under  seemingly  unfavorable  circumstances;  but 
only  too  often,  after  the  loss  of  the  patient  upon  whom  such  an  operation 
has  been  performed,  the  surgeon  is  compelled  to  refer  to  the  only  consolation 
possible,  which  is  that  the  patient  would  have  died  of  renal  disease  anyway, 
sooner  or  later. 

The  greatest  drawbacks  to  any  method  of  operation  for  prostatic  disease 
are:  (1)  the  danger  of  lighting  up  acute  hj'peremia,  or  even  infective  inflam- 
mation, in  already-damaged  kidneys;  (2)  the  ever-present  danger  of  sepsis. 
It  is  an  unfortunate  circumstance  that  we  have  no  very  accurate  data  for 
determining  the  precise  degree  of  so-called  surgical  nephritis  existing  in 
long-standing  cases  of  prostatic  disease.  We  are,  however,  justified  in  in- 
ferring considerable  renal  impairment  in  long-standing  cases  of  prostatic 
hypertrophy.  The  author  has  in  mind  at  the  present  moment  three  cases 
in  which  the  patient  was  lost  from  surgical  nephritis  after  all  danger  from 
the  operation  per  se  was  apparently  past.  One  of  these  was  a  case  of  his 
own  of  suprapubic  cystotomy,  followed  by  simple  drainage,  in  a  man  65 
years  of  age.  The  operation  was  done  in  two  stages.  The  bladder  having 
been  exposed,  the  wound  was  packed  with  iodoform  gauze,  puncture  of  the 
bladder  being  deferred  until  the  fifth  day.  At  the  time  of  vesical  puncture 
the  wound  was  in  a  perfectly  aseptic  condition.  Puncture  of  the  bladder  at 
this  juncture  was  certainly  a  very  simple  matter.  The  patient  was  anesthe- 
tized by  chloroform  in  both  operations,  and,  although  a  moderate  amount  of 
febrile  reaction  came  on  within  twenty-four  hours  after  the  first  operation, 
the  case  ran  a  distinctly  afebrile  course  thereafter.  On  the  third  day  fol- 
lowing the  second  operation  the  patient  suddenly  developed  uremia,  and 
died  in  coma  within  forty-eight  hours. 

On  autopsy  the  wound  was  found  to  be  healthy,  and  there  had  been  a 
distinct  subsidence  of  the  prostatic  tumor  felt  by  the  rectum.  This  was 
determined  not  only  post-mortem,  but  by  rectal  examination  before  the 
patient  died.  The  kidneys  were  found  to  be  distinctly  lobulated,  and  the 
seat  of  extensive  nephritis.  On  the  right  side  there  was  found  advanced  pye- 
lonephritis. Here  was  a  case  in  which  an  early  operation  would  probably 
have  saved  the  patient,  and  in  which  the  operation  per-  se  appeared  to  have 
nothing  to  do  with  the  result — of  which  more  anon. 

Another  suggestive  case  was  seen  in  consultation  with  Dr.  J.  B. 
Murphy.  For  many  months  this  man  had  been  catheterizing  himself 
through  a  perineal  fistula,  probably  made  in  the  Harrison  method  of  tun- 
neling the  prostate.  This  operation  had  been  performed  before  the  case 
fell  into  Dr.  Murphy's  hands.  Suprapubic  section  and  drainage  were  ad- 
vised. The  patient  was  operated  upon  and  did  well  for  two  weeks,  when 
he,  too,  suddenly  develo|)ed  uremia  and  died.     A  third  case,  operated  upon 


718  HTPEETEOPHT    OF    THE    PROSTATE. 

by  a  distinguished  surgeon  of  this  city,  died  in  a  similar  manner  about  three 
weeks  after  operation. 

The  author  believes  that  all  three  of  the  foregoing  cases  might  have 
been  saved  by  early  operation.  The  disturbance  of  micturition,  the  fre- 
quent passage  of  the  catheter,  successive  attacks  of  more  or  less  acute 
exacerbations  of  cystitis,  and  the  backward  pressure  upon  the  kidneys  in 
these  cases  inevitably  produce  serious  renal  disease,  which  comes  on  slowly, 
but  surely.  The  urine,  as  in  the  author's  case  just  mentioned,  may  contain 
little  or  no  albumin,  even  though  a  dangerous  degree  of  renal  disease  exists, 
and  a  fatal  result  may  be  precipitated  either  by  the  shock  of  operation,  by 
the  anesthetic, — ether  being  especially  open  to  criticism  in  this  respect, — 
or,  as  is  probably  the  cause  in  many  of  them,  the  sudden  removal  of  back- 
ward pressure  upon  the  kidneys.  This  removal  of  backward  renal  pressure 
was  undoubtedly  the  cause  of  death  in  the  three  cases  just  related. 
Anent  this  point  there  is  something  of  interest  to  be  said: — 
The  experiments  of  Guyon  and  Heubner  have  shown  that  an  obstruc- 
tion to  the  circulation  of  the  genito-urinary  tract,  followed  by  sudden  relief 
of  the  obstruction  in  cases  of  urinary  infection,  results  in  impairment  of 
tissue-resistance,  bacterial  infection,  and  fatal  inflammation.  This  explains 
septic  inflammation  of  the  bladder  following  sudden  evacuation  of  the 
urine  after  prolonged  retention  in  old  men.  It  is  conceivable  that  the  same 
condition  of  afEairs  may  exist  in  the  kidney.  The  large  amount  of  inter- 
stitial connective  tissue  and  consequent  strangulation  of  the  normal  kidney- 
parench3'ma  in  cases  of  surgical  nephritis  explains  why  the  kidney  can  ill 
withstand  circulatory  fluctuations.  There  is  no  method  of  avoiding  fatal 
renal  complications  following  operation  in  long-standing  disease  of  the  pros- 
tate and  bladder,  excepting  the  performance  of  operations  at  a  much  earlier 
period  than  they  are  now  usually  performed  and  the  use  of  chloroform  in 
lieu  of  ether  as  an  anesthetic.  It  must  be  understood  that  the  danger  of 
both  uremia  and  sepsis  is  in  direct  proportion  to  the  length  of  time  that 
operation  is  deferred.  In  many  cases  the  patient  is  advised  to  rely  upon  the 
use  of  the  catheter,  although  the  physician  acknowledges  that  the  time  will 
come  when  in  spite  of  the  catheter  the  patient  will  be  made  very  miserable 
by  his  prostatic  disease.  He  qualifies,  however,  by  saying  that  when  that 
time  arrives,  we  may  legitimately  consider  radical  operative  procedures. 
When  the  necessity  of  operation  finally  forces  itself  upon  the  physician  and 
his  patient,  the  kidneys,  in  a  large  proportion  of  cases,  are  so  far  impaired 
that  operation  either  precipitates  the  inevitable  or  defers  it  only  for  a  short 
time.  There  is  this  to  be  said  in  apology  for  the  fatal  uremia  that  follows 
operations  in  these  late  cases:  that  a  slight  exposure  to  cold,  an  attack  of 
retention  of  greater  or  less  duration,  or  some  dietetic  excess  may  precipitate 
an  acute  hyperemia,  or  even  inflammation,  with  resultant  fatal  uremia. 
Some  cases  dying  after  operation,  but  apparently  not  from  the  direct  effects 
of  the  operation,  are,  of  course,  in  all  probability  coincidences. 


TKEATMENT    OF   HYPEKTKOPHY    OF    THE    PKOSTATE.  719 

Early  operation  and  suprapubic  section  in  two  stages  may  be  said  to  be 
the  ideal  method  of  avoiding  the  deplorable  septic  results  that  frequently 
follow  operations  in  the  class  of  cases  under  consideration.  By  early  opera- 
tion we  avoid  exposing  the  area  wounded  in  the  operation  to  the  contact 
of  a  highly-noxious  fluid.  The  longer  operation  is  deferred,  and  the  more 
frequently  a  dirty  catheter  is  run  into  the  bladder,  the  more  toxic  the 
urine.  By  preliminary  suprapubic  section  and  exposure  of  the  bladder, 
and  tamponing  with  iodoform  gauze  for  four  or  five  days,  we  necessarily 
cut  off  avenues  of  infection  that  are  notoriously  ever  present  in  fresh  blad- 
der wounds.  A  thoroughly  aseptic  operation  in  cases  of  this  kind  with  a 
highly  infectious  state  of  the  urine  is  impracticable.  We  may  irrigate  the 
bladder  with  antiseptic  solutions  ever  so  thoroughly,  we  are  still  con- 
fronted by  two  factors  of  evil  import:  (1)  no  irrigating  fluid  will  remove 
all  of  the  septic  products  in  an  extensively-diseased  bladder;  (2)  no  anti- 
septic within  the  limits  of  tolerance  of  the  bladder  is  capable  of  destroying 
these  septic  materials,  even  providing  that  the  existing  mechanic  condi- 
tions permit  the  antiseptic  fluid's  coming  in  contact  with  them.  It  has 
been  by  no  means  infrequent  in  the  author's  experience  in  suprapubic  sec- 
tion after  thorough  irrigation  of  the  bladder,  on  exploring  the  bladder  with 
the  finger,  for  sacculi  to  evacuate  themselves,  with  the  result  that  a  greater 
or  less  amount  of  septic  fluid,  containing  perhaps  a  large  amount  of 
purulent  floceuli,  escapes  and  contaminates  the  wound.  No  method  of 
irrigation  will  so  aseptize  the  bladder  that  the  fluid  escaping  for  some  days 
after  operation  is  not  more  or  less  infectious. 

In  this  connection,  however,  attention  is  again  called  to  the  great 
value  of  the  internal  administration  of  oil  of  eucalyptus  in  lessening  the 
septic  qualities  of  the  urine.  In  cases  of  urinary  sepsis  of  a  minor  degree 
of  toxicity  this  drug  will  very  often  completely  prevent  septic  complica- 
tions. If,  however,  we  are  assured  that  the  kidneys  will  withstand  the  ef- 
fects of  the  operation  and  the  anesthetic,  we  need  not  be  greatly  alarmed 
as  to  possible  sepsis  when  the  operation  is  performed  in  two  stages  and  no 
cutting  is  done  within  the  bladder.  Old  prostatiques  are,  in  a  general  way, 
rather  more  resisting  to  infection  than  some  younger  subjects,  for  the  reason 
that  they  have  become  inured  to  a  certain  degree  of  toxemia  incidental  to 
the  prolonged  existence  of  the  septic  process  in  the  bladder. 

It  is  to  be  hoped  that  the  general  practitioner  will  ere  long  become  more 
appreciative  of  the  advantages  of  early  surgical  interference  in  prostatic 
disease.  There  is  no  reason  why  such  cases  should  be  allowed  to  suffer  in- 
describable torture,  to  die  finally  as  sacrificial  offerings  to  a  conservatism  that 
conserves  nothing  but  a  dangerous,  routine,  let-alone  policy  which  has  no 
place  in  surgery. 


720  HTPEKTEOPHT    OF    THE    PEOSTATE. 

TECHXIC    OF   OPEKATIOXS   FOE   THE   BELIEF   OF   EXLAEGED    PEOSTATE. 

SuPEAPUBic  C'TSTOTOiiT. — Tlie  teclmic  of  suprapubic  section  is  tlie 
same,  whetlier  designed  for  palliation  or  the  performance  of  radical  opera- 
tions upon  the  prostate  itself.  As  in  all  operations  upon  the  bladder,  the 
patient  should  be  kept  quietly  in  bed  for  a  few  days  prior  to  operation.  The 
diet  should  be  nourishing,  but  composed  largely  of  milk  in  various  forms. 
Care  should  be  taken  not  to  reduce  the  diet  too  much  in  advanced  cases,  for 
old  and  debilitated  patients  soon  become  exhausted,  thus  enhancing  the 
dangers  of  operation.  Quinin  and  eucalyptus  are  essential  as  a  preparatory 
measure.  If  the  stomach  does  not  tolerate  eucalyptus,  cystogen,  diuretin, 
or  boric  acid  may  be  given.  The  usual  preliminary  measures  of  evacuating 
the  bowel,  and  securing  asepsis  by  shaving  and  scrubbing  the  pubes,  scro- 
tum, and  perineum  are  practiced.  Chloroform  should  be  given  where 
general  anesthesia  is  employed.  The  bladder  should  be  thoroughly  irri- 
gated with  a  boric  solution,  or  1  to  20,000  mercury  bichlorid,  after  which  as 
much  of  the  solution  as  the  bladder  will  safely  hold  is  left  in  that  viscus. 
The  amount  varies  greatly — ^there  can  be  no  arbitrary  standard.  It  is  prob- 
ably safe,  on  the  average,  to  run  in  as  much  fluid  as  the  bladder  will  take 
under  the  pressure  that  can  be  secured  by  an  elevation  of  the  vessel  of  anti- 
septic solution  to  a  height  of  two  feet  above  the  level  of  the  bladder.  Mcety 
of  judgment  rather  than  accurate  measurement  is  a  sine  qua  non.  There  is 
no  objection  to  injecting  air  into  the  bladder  instead  of  antiseptic  fluid 
after  thorough  antiseptic  irrigation.  The  rectal  bag  of  Petersen  is  not 
necessary  in  suprapubic  cystotomy,  and  affords  an  element  of  danger  that 
is  entirely  unnecessary.    The  rectum  has  been  ruptured  by  it. 

An  incision  2  ^/o  to  4  inches  long  is  made  in  the  median  line,  just  above 
the  pubes,  and  extending  down  nearly  to  the  root  of  the  penis.  This  is  first 
carried  down  to  the  linea  alba.  A  small  incision  is  next  made  at  the  in- 
sertion of  the  muscular  aponeurosis  into  the  symphysis  pubis  midway  be- 
tween the  pubic  spines.  The  finger  is  inserted  into  this  opening,  and  upon 
it,  as  a  guide,  the  median  aponeurosis  is  slit  up  to  the  required  extent. 
Should  considerable  room  be  necessary,  a  transverse  incision  of  the  tendi- 
nous insertions  of  the  recti  muscles  close  to  the  pubic  rami  is  preferable 
io  extensive  prolongation  of  the  incision  upward,  hernia  being  more  likely 
to  result  by  the  latter  procedure.  At  the  bottom  of  the  wound  the  bladder 
may  now  be  felt,  covered  with  a  layer  of  fat,  the  upper  portion  of  which 
contains  the  prevesical  fold  of  the  peritoneum.  The  finger  should  be  passed 
down  behind  the  symphysis  pubis  until  the  neck  of  the  bladder  is  reached. 
Beginning  at  this  point,  the  prevesical  fat,  and  with  it  the  peritoneum,  is 
rolled  up,  apron-fashion,  to  the  upper  angle  of  the  wound,  where  it  is  held 
by  a  retractor  or  the  finger  of  an  assistant.  The  bladder  is  thus  freely  ex- 
posed. Eetention  sutures  are  now  passed  through  the  edges  of  the  wound 
and  deeply  into  the  muscular  wall  of  the  bladder  and  tied,  one  upon  each 


TREATMENT    OF    HTPEETEOPHT    OE    THE    PEOSTATE. 


721 


side.  The  bladder  is  now  opened  by  a  single  puncture  with,  a  bistoury.  So 
soon  as  the  knife  is  withdrawn  a  pair  of  forceps  should  be  introduced  as  a 
guide,  and  opened  so  as  to  stretch  the  vesical  wound  suf6.ciently  to  admit 
the  passage  of  the  index  finger  into  the  bladder.  All  necessary  explorations 
can  be  made  through  this  narrow  opening,  and  if  prostatectomy  or  pros- 
tatotomy  be  indicated,  the  opening  can  readily  be  enlarged.  In  case  simple 
drainage  is  decided  upon,  the  resultant  fistula  is  often  under  complete  con- 
trol, because  of  the  sphincter-like  action  of  the  longitudinally  linear  punct- 


Fig.   145. — Hunter  McGuire's  suprapubic-fistula  stem. 

ure  made  by  the  bistoury.  If  the  vesical  incision  is  made  well  down  toward 
the  vesical  neck,  it  closes  readily  in  case  no  further  operating  is  desirable. 
There  is  often  no  leakage  whatever  under  such  circumstances.  After  a 
drainage-tube  has  been  inserted  into  the  bladder,  a  strip  of  gauze  should 
be  passed  well  down  into  the  cavity  of  Eetzius — the  prevesical  space — and 
the  wound  closed  with  silk-worm-gut  and  catgut  sutures.  Siphon  drainage 
into  a  jar  of  antiseptic  solution  should  be  employed.  Should  a  permanent 
fistula  be  desirable,  McGuire's  stem  may  be  used  to  secure  patency. 


Fig.  146. — Rongeur  forceps  for  prostatectomy  and  similar  intravesical  work. 


Prostatotomt. — Division  of  the  tissues  constituting  the  obstruction 
at  the  neck  of  the  bladder  is  a  rational  operation  in  some  cases  of  prostatic 
hypertrophy.  The  intra-urethral  operation  by  the  galvanocautery,  devised 
by  Bottini,  has  until  recently  been  considered  so  uncertain  and  dangerous 
as  to  hardly  deserve  surgical  sanction.  It  has  recently  been  revived,  how- 
ever, and  may  have  a  future,  should  it  become  modified  so  as  to  be  in 
harmony  with  established  surgical  principles.  Division  of  the  so-called 
median  lobe,  or  bar  at  the  vesical  neck,  via  a  perineal  incision,  with  or 


732 


HYPERTEOPHY    OF    THE    PEOSTATE. 


without  suprapubic  section,  gives  good  results  in  a  fair  proportion  of  cases. 
The  mortality-rate  is  not  high,  but  would  be  much  lower  if  cases  were 
operated  earlier,  upon  the  average.  The  danger  is  in  deferring  operation 
until  the  kidneys  are  seriously  damaged  and  the  bladder  intensely  septic. 
The  author's  preference  is  for  the  combined  perineal  and  suprapubic 
method.  The  division  of  the  obstruction  should  be  made  with  a  blunt- 
pointed  knife.  Prolonged  drainage  with  a  large  tube  should  follow  the 
operation.  Much  of  the  benefit  in  favorable  cases  is  due  to  the  prolonged 
pressure  of  the  perineal  tube,  causing  absorption  of  the  diseased  tissue, 
and  to  subsequent  cicatricial  contraction. 

Peostatectomy. — The  preliminary  steps  comprise  suprapubic  or  peri- 
neal section,  or  both.  The  author's  preference  is  for  the  combined  method. 
After  exploring  the  bladder  thoroughly  with  the  finger  and  outlining  all 
circumscribed  growths,  the  latter  should  be  removed.  It  is  rarely  neces- 
sary to  do  much  cutting  inside  the  bladder.    An  incision  is  made  over  the 


Fig.  147. — Saw-tooth  scissors  for  intravesical  work. 


most  prominent  point  of  each  tumor,  just  large  enough  to  admit  the  index 
finger.  Through  this  opening  the  growth  may  usually  be  shelled  out  of  its 
capsule  piecemeal.  Pedunculated  growths  may  be  torn  or  twisted  off  with 
the  finger.  Eongeur  forceps  or  scissors  may  be  necessary  in  some  cases,  but 
should  be  dispensed  with  where  possible.  The  chief  indication  is  to  min- 
imize vesical  traumatism.  Following  the  operation  drainage  by  the  com- 
bined method  should  be  persisted  in  for  several  weeks. 

In  some  cases  it  is  practicable  to  remove  the  entire  growth  by  blunt 
dissection  via  the  perineum  (Alexander).  The  prostate  is  pressed  well  down 
into  the  perineum  by  the  fingers  of  an  assistant  within  the  bladder.  The 
author  has  succeeded  in  removing  the  prostate  via  the  perineum  without 
opening  either  the  bladder  or  urethra.  It  is  surprising  with  what  readiness 
the  prostate  may  often  be  brought  within  reach  by  hooking  it  down  with  the 
fingers  in  the  rectum. 

The  control  of  hemorrhage  is  often  a  very  important  consideration  in 
cutting  operations  upon  the  prostate.  Under  ordinary  conditions  the  peri- 
neal tube  devised  by  the  author  is  effective  in  controlling  hemorrhage. 


TEEATMENT    OF   HYPEETROPHY    OF    THE    PEOSTATE. 


723 


(Fig.  148.)  It  is  provided  with  an  inner  tube  to  facilitate  cleaning,  in  case 
it  becomes  obstructed  by  blood-clot  or  otherwise,  and  has  grooves  for  petti- 
coats of  iodoform  gauze,  within  which  the  wound  may  be  packed  with 
gauze  strips.    Hot  water  is  often  effectual  in  checking  obstinate  oozing. 

In  severe  cases  the  bladder  may  be  tamponed  with  gauze.  A  petticoat 
may  be  drawn  down  via  the  suprapubic  opening  through  the  perineal 
wound,  and  the  vesical  neck  packed  with  gauze  within  the  petticoat  as 
liberally  as  may  be  necessary  to  control  the  bleeding.  There  is  no  special 
danger  in  packing  the  bladder  full  of  gauze  and  leaving  it  in  situ  for  some 
hours.  It  should  be  removed  a  little  at  a  time,  enough  being  removed  to 
relieve  the  intravesical  pressure  as  soon  after  the  operation  as  practicable. 
A  gauze  petticoat  may  be  pushed  into  the  bladder  from  the  perineum  and 
packed  with  gauze. 

Frequent  irrigation  with  warm  boric  solution  should  be  practiced  after 
vesico-prostatic  operations. 


Fig.  148. — Author's  perineal  drainage-tube. 


Casteation. — The  operation  of  castration,  first  suggested  by  Eamm 
and  developed  by  White,  as  a  cure  for  prostatic  hypertrophy  was  for  a  time 
a  very  popular  method  of  treatment.  It  seems,  however,  to  be  losing  ground 
as  a  routine  procedure.    Whitens  remarks  on  the  operation  are  as  follow^: — 

The  apparent  analogy  between  uterine  and  prostatic  growths  first  suggested 
the  idea  of  castration  for  prostatic  hypertrophy.  The  analogy  is  as  follows:  The 
prostatic  vesicle  is  the  analogue  of  the  sinus  genitalis  in  the  female, — the  uterine  and 
vaginal  cavities;  the  structm-e  of  the  prostate  and  that  of  the  uterus  are  strikingly 
similar,  and  would  be  almost  identic  if  the  tubular  glands  found  in  the  inner  walls 
of  the  uterus  were  prolonged  into  its  substance;  the  histology  of  its  growths,  from 
small  incapsulated  tumors  easily  shelled  out,  or  polypoid  growths  intimately  con- 
nected with  the  uterus  or  the  prostate,  up  ±o  the  enormous  growths  which  far  ex- 
ceed the  original  bulk  of  the  organ  itself,  is  identic;  or  there  may  be  in  either  case 
a  general  hypertrophic  enlargement  affecting  the  whole  organ;  lastly,  these  dis- 
turbances occur  at  about  the  same  time  in  the  sexual  life  of  the  two  sexes — that  is, 
during  the  latter  half  of  the  reproductive  period.  This  ends  sooner  in  the  female  than 
in  the  male,  and  accordingly  we  find  the  growths  appearing  in  the  former  at  a  some- 


^  White  and  Martin :    "Genito-Urinary  Diseases." 


.724  HYPEETEOPHY    OF    THE    PEOSTATE. 

what  earlier  age.  This  analogy  is  said  by  embryologists  to  be  without  foundation 
as  regards  any  true  homology  between  the  prostate  and  the  uterus.  The  clinical 
resemblances  between  the  two  forms  of  overgrowth  are,  however,  none  the  less 
striking,  and  it  may  now  be  said  that  the  results  of  castration  in  such  cases  are 
equally  similar  and  remarkable  in  each  sex. 

Even  though  the  prostate  is  not  the  absolute  homologue  of  the  uterus,  as  it 
contains  and  encircles  the  cavity  which  is  said  to  be  the  absolute  homologue,  the 
utricle,  or  prostatic  vesicle,  the  relationship  between  the  two  is  notably  close.  So, 
too,  although  the  uterine  growths  begin  as  fibromyomata,  and  the  prostatic  as  adeno- 
mata or  adenofibromata,  the  difference  merely  corresponds  with  the  differences  in 
structure  of  the  two  organs,  the  prostate  containing  normally  more  glandular  tissue 
than  the  uterus. 

An  experimental  investigation  on  dogs  (White,  Kirby)  proved  conclusively  that 
after  castration  the  glandular  tissue  of  the  prostate  first  atrophies  and  disappears,  this 
atrophy  beginning  within  a  few  days. 

Soon  after  the  publication  of  the  first  paper  on  this  subject  clinical  evidence  as 
to  the  value  of  the  treatment  began  to  accumulate,  and  in  a  short  time  was  over- 
whelmingly favorable.  In  several  cases  autopsies  have  been  made  which  demonstrate 
the  exact  nature  of  the  shrinkage,  and  show  that  it  is  due  to  the  same  sort  of  atrophy, 
first  of  the  glandular  elements,  then  of  the  stroma,  that  was  originally  reported  as 
the  invariable  result  of  castration  of  dogs.  Nearly  all  varieties  of  enlargement  are 
probably  originally  adenomatous;  hence  such  growths  would  naturally  begin  where 
glandular  tissue  is  most  abundant.  This  is  in  the  posterior  commissure,  the  so-called 
median  lobe,  enlargement  of  which,  from  its  position,  more  effectually  blocks  the 
urethra  than  overgrowth  of  any  other  portion  of  the  prostate. 

The  indications  for  castration  are  those  for  any  form  of  surgical  intervention: 
i.e.,  beginning  breakdown  of  catheter-life.  At  this  time  the  patient  is  usually  im- 
potent; hence  the  removal  of  the  testicles  is  not  objectionable  except  for  sentimental 
reasons.  The  operation  is  further  indicated  in  those  cases  of  advanced  bladder  and 
kidney  disease  combined  with  retention  of  urine  in  which  the  general  condition  is  so 
unfavorable  that  any  prolonged  operation  is  likely  to  be  immediately  fatal. 

Castration  can  be  performed  in  from  three  to  five  minutes,  is  bloodless,  and  is 
attended  with  almost  no  shock.  Vasectomy  can  be  performed  in  even  less  time,  and 
does  not  require  the  administration  of  ether.  As  to  the  clinical  results  of  castration. 
Wood  reports  143  cases  of  this  operation,  including  in  this  number  those  collected  by 
Cabot;  117  of  these  recovered  (82  per  cent.)  :  26  died  (18  per  cent.).  Of  the  117  cases 
which  recovered,  improvement  Avas  noted  in  110  (94  per  cent.);  4  were  not  improved. 
In  63  cases  (53Vio  per  cent.)  it  was  noted  that  the  prostate  was  reduced  in  size.  Of 
Wood's  last  series  of  cases  (92)  the  mortality  was  9  '/lo  per  cent.;  rejecting  two  cases 
in  which  death  was  in  no  way  attributable  to  the  operation,  and  apparently  was 
not  hastened  by  it,  there  is  left  a  legitimate  mortality  of  7  ^/m  per  cent.  One  of  the 
most  surprising  and  satisfactory  results  of  castration  has  been  the  return  of  power 
in  the  bladder  (66  per  cent.)  and  the  disappearance  of  cystitis.  It  is  certain  that 
Sir  Henry  Thompson's  assertion  that  the  return  of  voluntary  power  in  the  bladder  is 
impossible  after  two  years'  use  of  the  catheter  is  not  correct. 

There  is  no  conclusive  method  of  determining  in  advance  whether  a  particular 
bladder  is  hopelessly  dilated  and  atonic  or  still  possesses  the  power  of  recuperation.  In 
many  cases  the  evidence  of  continued  contractility  will  be  unmistakable;  but,  even 
after  complete  retention,  with  the  withdrawal  of  urine  exclusively  by  the  catheter  for 
years,  there  has  been  noted  a  satisfactory  return  of  power  in  the  detrusor,  in  some 
instances  amounting  almost  to  perfect  health.  Enough  cases  have  now  been  followed 
for  a  sufficient  length  of  time  to  warrant  belief  in  the  permanence  of  the  cure  when 
once  effected   (75  per  cent.). 


TEEATMEXT    OF    HYPEETEOPHY    OF    THE    PEOSTATE.  73o 

The  legitimate  average  mortality  of  the  cases  operated  on  with  a  reasonable  ex- 
pectation of  cure  is,  as  has  been  said,  about  7  per  cent.,  and  will  probably  be  less  in 
future.  If  so,  it  will  accord  with  the  history  of  every  new  operation  in  the  matter 
of  mortality.  A  table  of  ninety-five  cases  of  suprapubic  prostatectomy  shows  a  mor- 
tality of  20  per  cent,  for  the  whole  number,  but  only  15  per  cent,  for  the  last  half. 
The  mortality  of  the  first  half  is  25  per  cent.  Careful  impartial  study  of  the  cases  of 
fatality  following  castration  for  enlarged  prostate  will  show  that  in  the  majority  of 
those  as  to  Avhich  details  are  given  there  was  little  to  be  hoped  for  from  palliative 
operations  and  less  from  the  unaided  efforts  of  Nature,  while  it  seems  highly  probable 
that  any  other  radical  procedure  would  have  been  at  least  equally  likely  to  result 
fatally.  Even  the  fatal  cases,  it  is  interesting  to  note,  showed  distinct  improvement 
in  the  symptoms,  or  some  shrinkage  in  the  prostate  after  death.  While  there  is  little 
or  no  risk  in  the  operation  itself,  if  it  is  applied  in  the  future  as  ^videly  as  it  has 
already  been — i.e.,  to  patients  of  all  ages  and  all  degrees  of  weakness,  with  uremia 
and  toxemia — it  will  undoubtedly  always  haA'e  a  considerable  mortality. 

It  is  probable  that  the  mortality  of  the  operation  will  be  found  to  have  a  very 
direct  relation  to  a  few  factors,  the  most  important  being  the  presence  or  the  absence 
of  renal  infection,  and  the  history  of  long-continued  catheter-life,  or  a  number  of 
attacks  of  complete  retention,  or  of  a  very  large  amount  of  residual  urine.  When 
tl^ese  factors  are  conjoined  the  case  is  of  the  most  unfavorable  type.  Differences  in 
the  size,  density,  and  shape  of  the  prostatic  overgrowth  will  probably  be  found  to  be 
minor  factors  in  determining  mortality,  but  they  have  an  important  relation  to  the 
degi'ee  of  improvement  effected  by  the  operation  and  the  rapidity  with  which  it 
occurs.  The  remote  results  of  the  operation  cannot  yet  be  determined.  Cases  of  death 
with  precedent  mental  symptoms,  described  as  mania,  acute  mania,  etc.,  are  only  such 
as  every  surgeon  is  familiar  with  in  a  certain  proportion  of  operations  done  upon 
aged  persons,  whose  mental  equilibrium  is  easily  disturbed,  and  can  have  no  bearing 
upon  the  question  of  later  mental  changes  as  the  result  of  castration.  With  greater 
accuracy  we  should  probably  classify  the  large  majority  of  them  as  uremia  and  some 
of  the  remainder  as  traumatic  delirium.  Clinical  evidence  leads  to  the  belief  that  the 
removal  of  the  testicles  from  persons  who  have  reached  full  adult  life  has  no  effect 
upon  the  mental  functions  or  upon  the  general  physical  characteristics.  Impotence 
will  undoubtedly  be  caused  in  the  majority  of  cases,  but  even  this  is  not  immediate 
or   inevitable. 

The  conclusions  which  seem  warranted  by  the  arguments  and  the  facts  set  forth 
in  the  foregoing  are  as  follow:— 

1.  The  function  of  the  testis,  like  that  of  the  ovary,  is  twofold:  the  reproduction 
of  the  species  and  the  development  and  preservation  of  the  secondary  sexual  char- 
acteristics of  the  individual.  The  need  for  the  exercise  of  the  latter  function  ceases 
w^hen  full  adult  life  is  reached,  but  it  is  possible  that  the  activity  of  the  testis  and 
that  of  the  ovary  in  this  respect  do  not  disappear  coincidently,  and  that  hypertrophy 
in  closely  allied  organs  like  the  prostate  and  the  uterus  is  the  result  of  this  mis- 
directed  energy. 

2.  The  theoretic  objections  which  have  been  urged  against  the  operation  of 
double  castration  have  been  fully  negated  by  clinical  experience,  which  shows  that 
in  a  very  large  proportion  of  cases  (thus  far  in  more  than  80  per  cent.)  rapid  atrophy 
of  the  prostatic  enlargement  follows  the  operation,  and  that  disappearance  or  great 
lessening  in  degree  of  long-standing  cystitis  (52  per  cent.),  more  or  less  return  of 
vesical  contractility  (66  per  cent.),  amelioration  of  the  most  troublesome  symptoms 
(89  per  cent.),  and  a  return  to  local  conditions  not  very  far  removed  from  normal  (50 
per  cent.)  may  be  expected  in  a  considerable  number  of  cases. 

3.  In  patients  operated  upon  under  surgically  favorable  conditions — i.e.,  before 
the  actual  onset  of  uremia,  or,  better,  before  the -kidneys  have  become  disorganized  by 


726  HYPERTROPHY    OF    THE    PROSTATE. 

the  two  factors  rarely  absent  in  advanced  cases, — backward  pressure  and  infection — 
there  has  been  a  mortality  of  about  7  per  cent.,  which  will  probably  be  decreased 
as  advancing  knowledge  permits  of  a  better  selection  of  cases.  It  is  important  to  note 
that  even  in  the  desperate  cases  which  made  up  the  series  of  deaths  in  the  first  col- 
lection of  cases  a  very  large  percentage  (75  per  cent.)  showed  improvement  of  symp- 
toms or  shrinkage  of  the  prostate  before  they  died. 

4.  Comparison  with  other  operative  procedures  seems  to  justify  the  statement 
that,  apart  from  he  sentimental  objections  of  aged  persons,  on  the  one  hand,  and  the 
real,  entirely  natural,  and  very  strong  repugnance  to  the  operation  felt  by  younger 
patients,  castration  offers  a  better  prospect  of  permanent  return  to  nearly  normal 
conditions  than  does  any  other  method  of  treatment.  The  relatively  greater  degree 
of  improvement  in  successful  cases  should  be  considered,  as  well  as  the  mortality,  in 
comparing  the  operation  with  the  various  forms  of  prostatotomy  and  prostatectomy. 
SOj  too,  should  the  absence  of  any  risk  of  permanent  fistulas,  perineal  or  suprapubic, 
the  ease  and  quickness  with  which  the  operation  can  be  performed,  and  the  possibility 
of  avoiding  altogether  the  use  of  anesthetics,  which,  in  these  cases,  are  in  themselves 
dangerous. 

5.  The  evidence  as  to  unilateral  castration  is  at  present  contradictory,  but  there 
can  be  no  doubt  that  in  some  cases  it  is  followed  by  unilateral  atrophy  of  the 
prostate,  and  in  two  cases,  at  least,  it  has  resulted  in  a  very  marked  improvement 
of  symptoms.     It  is  worthy  of  further  investigation. 

6.  Experiments  on  dogs  have  shown  in  nearly  every  case  in  which  the  vas 
deferens  was  tied  or  divided  on  both  sides  that,  without  much  change  in  the  testicles, 
there  were  beginning  atrophy  and  considerable  loss  of  weight  of  the  prostate.  Opera- 
tions performed  on  man  have  given  similar  results.  It  is  possible  that  the  inclusion  or 
severance  of  small,  but  important,  nerves  may  account  for  the  effect  on  the  prostate. 

7.  Ligation  of  the  vascular  constituents  of  the  cord,  or  of  the  whole  cord,  pro- 
duces atrophy  of  the  prostate,  but,  at  least  in  experiments  on  dogs,  only  after  first 
causing  disorganization  of  the  testis. 

The  Bottini  method  of  division  of  the  obstruction  on  the  floor  of  the 
prostate  in  prostatic  hypertrophy  with  the  galvanocautery-knife  did  not 
fulfill  the  expectations  of  its  originator,  and  scarcely  went  beyond  the  ex- 
perimental stage.  It  has  recently  been  revived,  however,  and  with  the  im- 
proved Bottini-Freudenberg  instrument  has  given  some  apparently  good 
results.  It  is  too  early  as  yet  to  form  positive  conclusions  as  to  its  value. 
Much  experimentation  will  be  necessary  to  determine  its  true  position  in 
the  operative  treatment  of  prostatic  disease.  Its  field  of  usefulness  must 
necessarily  be  limited  to  cases  in  which  the  obstruction  is  chiefly  confined 
to  the  prostatic  floor.  It  remains  to  be  seen,  however,  how  much  shrinkage 
of  the  remainder  of  the  hypertrophied  tissue  may  result  from  the  nutri- 
tional change  and  relief  of  irritation  induced  by  the  cautery.  In  a  general 
way,  it  may  be  said  that  serious  surgical  operations  upon  the  bladder  per- 
formed in  the  dark  are  to  be  very  carefully  tested  before  being  given  the 
stamp  of  authority.  The  author  believes  that  serious  operations  upon  the 
bladder,  or  about  the  vesical  neck,  should  rarely  be  perfo-rmed  without  pro- 
vision for  free  access  to  the  bladder  for  the  control  of  hemorrhage,  accuracy 
of  manipulation,  and.  free  drainage,  by  cystotomy — perineal  or  suprapubic. 
Still,  as  already  observed,  the  operation  has  not  yet  been  fairly  tested,  and 


TEEATMENT    OF    HYPEETEOPHT    OF    THE    PEOSTATE. 


737 


future  experience  may  alter  this  view.  The  author  is  of  opinion  that  the 
safety  and  success  of  the  operation  is  hkely  to  be  enhanced  by  combining  it 
with  perineal  drainage.- 


Fig.    149. — Bottini-Freudenberg    electroprostatome. 


The  table  of  all  the  Bottini-Freudenberg  operations  thus  far  gathered 
by  Meyer  from  reliable  sources  is  as  follows: — 


Operator. 


Cases. 


Cured. 


Much 
Improved. 


Little 

or  Not 

Improved. 


Death 
Directly  or 
Indirectly 
Due  to  the 
Operation. 


Death 
Independent 

from 
Operation. 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 


Bottini 

Bruce  Clark   ... 
Freudenberg  ... 

Czerny 

Meyer 

Weber  and  Torek . 

Morton 

Hanc 

Eochet 

Viertel 

Lohnstein   .... 
Jemoli  and  Marconi 
Lennander .... 

Floderus 

Casper 

Wossidlo     .... 

Lewis 

Downes , 


57 
1 

32 
8 

13 
1 
5 
5 
2 

10 

12 
2 
4 
3 
5 
1 
2 
1 


164 


32 

13 

4 


80 


11 
1 

11 
1 
2 
1 
2 
3 


12 

3 

1 


44 


26 


This  is  certainly  an  encouraging  showing  thus  far.  It  remains  to  be 
seen  how  the  record  will  stand  when  the  surgical  rank  and  file  get  to  work 
with  the  operation  in  real  earnest. 


CHAPTER  XXXI. 

Diseases  of  the  Seminal  Vesicles. 

Diseases  affecting  the  seminal  vesicles  have  only  recently  received  spe- 
cial consideration  at  the  hands  of  pathologists.  In  a  general  way,  the  dis- 
eases of  these  organs  have  hitherto  received  attention  only  as  conditions 
secondary  to  diseases  of  the  urethra,  bladder,  and  prostate;  in  other  words, 
as  a  p^rt  of  the  pathologic  ensemble  presented  by  gonorrhea,  cancer,  and 
tuberculosis.  The  profession  is  but  Just  beginning  to  understand  that  dis- 
ease of  the  seminal  vesicles  bears  a  relation  almost  as  important,  and  quite 
similar,  to  the  male  genito-urinary  organs  that  Fallopian  disease  does  to 
ovarian  and  uterine  disturbances  in  the  female.  The  most  frequent  and  im- 
portant disease  of  the  seminal  vesicles  is  gonorrheal  infection.  When  once 
this  has  occurred,  the  author  believes  that  perfect  restoration  of  the  vesicles 
to  a  healthy  condition  never  occurs.  It  must  be  remembered,  however,  that 
the  condition  does  not  necessarily  remain  gonorrheal;  on  the  contrary,  gono- 
cocci  may  disappear  from  the  semen,  although  the  vesicles  remain  in  a  dis- 
eased condition  for  an  indefinite  period — probably  always  pathologically,  if 
not  clinically.  The  gonococcus,  too,  may  become  transformed  into  a  germ 
which  to  all  intents  and  purposes  is  innocuous,  but  which,  when  conveyed 
to  a  new  and  favorable  environment,  such  as  is  presented  by  an  unhealthy 
genital  tract  in  the  female  may  possibly  again  acquire  pathogenic  properties. 
This  is  rather  a  broad  proposition,  but  the  author  has  observed  cases  that 
apparently  bear  out  its  truth.    The  following  case  is  one  in  point:— 

Case. — A  gentleman,  30  years  of  age,  consulted  the  author  for  chronic  gonorrheal 
infection  of  the  seminal  vesicles,  which,  he  asserted,  had  existed  for  three  years.  He 
had  a  slight  stricture,  but  had  had  no  discharge  for  nearly  two  years.  The  semen, 
however,  had  been  examined  at  frequent  intervals  during  the  entire  period  of  his 
affliction,  and  had  been  shown  to  contain  gonococci.  The  examinations  had  been  made 
by  several  gentlemen  of  acknowledged  expertness  in  microscopic  research.  In  eon- 
junction  with  Professor  William  A.  Evans,  of  the  Columbus  Laboratory,  the  author 
made  careful  studies  of  the  alleged  gonococci  found  in  abundant  quantity  in  the 
semen.  Their  physical  appearance  and  staining  reaction  were  precisely  identic  with 
the  ordinary  gonococcus.  Culture  and  inoculation  experiments,  however,  showed 
them  to  be  an  indeterminate  type  of  organism,  having  no  pathogenic  properties  in 
common  with  the  gonococcus.  Notwithstanding  this  fact,  however,  the  author  be- 
lieves that  the  germs  in  this  case  were  lineal  descendants  of  the  gonococcus  that  might 
evolve  pathogenic  properties  under  favorable  circumstances  of  environment.  Believ- 
ing that  such  an  evolution  would  not  occur  in  the  genital  tract  of  a  healthy  woman, 
the  author  sanctioned  the  patient's  marriage;  this  sanction  has  not  yet  been  taken 
advantage  of,  so  that  there  is  no  clinical  evidence  available  in  that  particular  direction. 

A  similar  case  in  a  physician  came  recently  under  the  author's  obser- 
vation.   This  patient  had  been  making  frequent  examinations  of  his  semen 
for  gonococci,  and,  finding  them,  as  he  supposed,  constantly  present,  was 
very  much  alarmed  at  his  condition. 
(738) 


SEMINAL    VESICULITIS.  729 

Great  credit  is  due  Jordan  Lloyd,  of  Birmingham,  England,  for  having 
called  attention  some  years  ago  to  the  prolonged  infection  of  the  seminal 
vesicles  that  frequently  follows  gonorrhea. 

Seminal  Vesiculitis. — Chronic  seminal  vesiculitis  is  a  condition  very 
frequently  seen.  The  profession  is  greatly  indebted  to  Fuller  for  his  re- 
searches upon  this  subject.^  His  book  upon  diseases  of  the  seminal  vesicles 
is  destined  to  become  a  classic.  Seminal  vesiculitis  is  not  only  dangerous 
from  the  stand-point  of  infection,  but  it  produces  various  psychic  and 
organic  disturbances  of  both  the  sexual  and  urinary  functions. 

The  causes  of  seminal  vesiculitis  are  several,  viz.:  1.  Gonorrheal  in- 
fection. This  is  the  most  frequent  and  important  of  all  causes.  2.  Simple 
infection  from  urethritis  of  non-gonorrheal  character.  3.  Prostatic  disease 
involving  the  seminal  vesicles  secondarily.  4.  Masturbation  and  sexual  ex- 
cess. Prolonged  sexual  excitement  without  gratification  enters  into  consid- 
eration here.  These  various  etiologic  factors  may  be  assisted  in  their  opera- 
lion  by  such  local  sources  of  irritation  as  bicycling  and  horseback-riding 
and  by  the  gouty  and  rheumatic  diatheses. 

Symptoms. — The  symptoms  of  seminal  vesiculitis  vary  according  to  the 
acuteness  of  the  process  and  the  character  and  degree  of  the  associated  pri- 
mary or  secondary  conditions.  Thus,  when  the  prostatic  urethra  is  involved, 
the  function  of  micturition  is  markedly  disturbed.  In  other  instances  the 
only  symptoms  are  referable  entirely  to  the  sexual  function.  Hemorrhagic 
emissions,  frequent  emissions,  abnormal  sexual  excitement,  impotency,  pre- 
mature ejaculation,  painful  orgasm — all  these  conditions  may  arise  in  dif- 
ferent cases. 

In  acute  seminal  vesiculitis  the  vesicles  are  involved  in  the  general  in- 
flammation of  the  parts  about  the  neck  of  the  bladder:  i.e.,  the  prostate  and 
surrounding  cellular  tissue.  Under  such  circumstances  the  acute  inflamma- 
tion of  the  seminal  vesicles  is  merely  a  part  of  the  prostatic  disease.  In 
most  instances  of  the  chronic  variety  the  prostate  is  involved  to  a  greater 
or  less  extent.  In  other  instances,  however,  there  is  very  little  disturbance 
of  the  prostate,  the  acute  trouble  having  subsided  without  leaving  any  ap- 
preciable change  in  that  organ,  while  the  seminal  vesicles  are  still  markedly 
involved. 

When  the  process  is  acute  or  subacute  a  sensation  of  throbbing,  weight, 
and  quasivoluptuousness  in  the  perineum,  perhaps  with  more  or  less  peri- 
neal tenderness,  are  experienced,  these  symptoms  depending  largely  upon 
the  amount  of  prostatic  disturbance.  A'^oluptuous  sensations  mingled  with  a 
certain  amount  of  pain  and  tenderness  during  defecation,  particularly  if  the 
bowels  be  constipated,  are  often  noted.  The  perturbations  of  the  sexual 
function  already  mentioned  also  enter  into  the  symptomatology.  Hemor- 
rhagic emissions  are  a  very  important  symptom  in  some  acute  cases. 


^  "Diseases  of  the  Seminal  Vesicles,"  E.  Fuller. 


730  DISEASES    OF    THE    SEMHSTAL   VESICLES. 

Diagnosis. — The  diagnosis  is  established  by  digital  exploration  per  rec- 
tum. The  distended,  thickened,  and  tender  seminal  Tesicles  are  plainly  per- 
ceptible to  the  examining  finger.  The  local  conditions  vary  according  to  the 
degree  to  which  the  prostate  and  surrounding  cellular  tissue  are  involved. 
It  is  the  author's  belief  that  a  greater  or  less  amount  of  lymphatic  hyper- 
plasia is  a  very  important  element  in  chronic  inflammation  in  this  region. 

Treatment. — The  treatment  of  seminal  vesiculitis  comprises  (1)  treat- 
ment directed  to  the  vesicles  themselves;  (3)  measures  for  the  correction 
of  associated  conditions. 

Whether  the  associated  conditions  be  primary  or  secondary,  sexual  rest  is 
a  sine  qua  non.  Massage  of  the  seminal  vesicles  per  rectum,  associated  with 
instillations  of  astringents — such  as  silver  nitrate,  copper  sulphate,  protargol, 
and  thallin  sulphate — are  essential.  These  instillations  should  be  given  in 
relatively  weak  solution,  but  in  large  amount,  and  should  precede  the  massage. 
By  this  method  more  or  less  fluid  is  made  to  enter  the  mouths  of  the  pro- 
static and  ejaculatory  ducts,  thus  obtaining  an  alterative  effect  upon  the 
chronic  inflammation  that  very  likely  affects  these  structures.  It  is  prob- 
able that  in  some  instances  the  astringent  fluid  is  forced  into  the  ducts  of 
the  prostate  for  a  sufficient  distance  to  materially  modify  the  chronic  in- 
flammation of  that  organ.  In  conjunction  with  these  remedies  the  passage 
of  the  sound  from  time  to  time  is  useful.  All  contractions  or  other  diseased 
conditions  of  the  urethra  demand  attention,  and,  so  far  as  possible,  should 
be  removed.  Infection  of  the  urethra  and  bladder  should  be  treated  by  irri- 
gations and  such  internal  remedies  as  are  indicated  under  ordinary  circum- 
stances. The  Oberlaender  method  of  dilation  and  irrigation  has  proved  of 
service  under  such  conditions.  It  mu.st  be  remembered  that  no  treatment 
of  the  diseased  seminal  vesicles  is  likely  to  prove  effective  unless  associated 
infectious  conditions  of  the  mucous  membrane  of  the  urethra  and  bladder, 
and  particularly  of  the  prostatic  urethra,  are  treated  simultaneously.  Care- 
ful restriction  of  the  diet, — which  should  be  as  non-stimulating  as  possible, 
— avoidance  of  all  sources  of  sexual  excitement,  and  abstinence  from  to- 
bacco and  liquor  should  be  insisted  upon.  Bicycling  and  horseback-riding 
should  be  strictly  interdicted.  Attention  should  be  paid  to  the  bowels  and 
condition  of  the  skin.  Tonics  and  anaphrodisiacs  are  usually  indicated, 
and  should  be  of  such  character  and  dosage  as  seem  to  be  demanded  in 
each  particular  case.  Eectal  injections  of  lai*ge  quantities  of  hot  water  are 
a  useful  adjuvant. 

The  author  desires  to  lay  especial  stress  upon  the  fact  that  careful  treat- 
ment of  morbid  conditions  of  the  seminal  vesicles  is  very  often  effective  in 
curing  otherwise  incurable  cases  of  impotency. 

It  is  noteworthy  that,  in  many  cases  in  which  prostatic  massage  is  at- 
tempted by  the  practitioner,  it  is  inadequately  and  inaccurately  performed. 
Too  much  or  too  little  force  is  employed,  and,  unless  the  physician  has  an 
extremely  long  index  finger  and  a  well-developed  tactus  eruditus,  it  is  prob- 


TUBERCULOSIS    AND    CANCER    OF    THE    SEMINAL    VESICLES.  731 

able  that  in  the  majority  of  instances  the  seminal  vesicles  are  either  not 
massaged  at  all  or,  at  most,  imperfectly.  This  is  the  author's  conclusion 
from  observation  in  the  treatment  of  cases  that  have  been  said  to  have  pre- 
viously had  prolonged  massage  treatment  for  seminal  vesiculitis. 

Tuberculosis  and  Cancer  of  the  Seminal  Vesicles. — Tuberculosis 
and  cancer  of  the  seminal  vesicles  practically  do  not  occur  as  primary  condi- 
tions. There  may  be  certain  rare  exceptions  to  this  rule,  but  they  are  so 
rare  as  not  to  be  of  practical  importance.  The  seminal  vesicles  have  been 
operated  upon  in  certain  cases  for  the  relief  of  tubercular  disease.  Where 
the  disease  is  apparently  limited  to  these  structures  an  operation  may  per- 
haps be  warrantable,  but  the  author  ventures  the  opinion  that  in  most  of 
the  cases  of  alleged  primary  tuberculosis  of  the  seminal  vesicles  the  con- 
dition is  an  induration  incidental  to  chronic  seminal  vesiculitis  of  infectious 
origin.  This  will  yield  to  massage  and  the  other  measures  of  treatment  al- 
ready suggested,  perhaps  not  to  the  extent  of  complete  cure  in  all  cases,  buf 
to  a  sufficient  degree  to  render  the  patient  perfectly  comfortable. 

Extirpation  of  the  seminal  vesicles  is  a  serious  matter  for  consideration, 
and  unless  the  disease  be  proved  to  be  limited  entirely  to  the  vesicles — which 
is  difficult  to  do — operations  for  their  removal  should  not  be  undertaken. 
Moullin  has  recently  reported  a  case  of  excision  of  one  seminal  vesicle  for 
chronic  gonorrheal  inflammation.  It  is  to  be. hoped  that  this  is  not  the 
beginning  of  a  new  fad. 


PART  VIII. 

DISEASES  OF  THE  UEINAEY  BLADDEE. 


CHAPTER  XXXII. 

DISEASES  OF  THE  URUSTARY  BLADDER. 

Anatomy  of  the  Bladdee;  Ruptuke  of  the  Bladdee;  Foeeign  Bodies 
IN  THE  Bladdee;  Exsteophy  of  the  Bladdee;  Cystitis,  Acute 
AND  Cheonic;  Vesical  Ulcee;  Vesical  Abscess;  Vesical  Gan- 
geene;   Vesical  Hypeeteophy  and  Ateophy. 

anatomy. 

The  bladder  is  a  hollow,  membranous  visciis  situated  in  the  pelvic 
cavity  between  the  pnbes  and  rectum  in  the  male,  and  between  the  uterus 
and  pubes  in  the  female.  It  is  divisible  into  (1)  the  body,  or  middle  por- 
tion; (2)  the  fundus,  or  upper  segment;  (3)  the  base,  or  broad  lower  seg- 
ment resting  on  the  rectum;  and  (4)  the  pseudoneck,  or  constricted  portion 
adjoining  the  prostate,  that  constitutes  its  outlet. 

Ligaments. — The  bladder  is  held  in  position  by  two  anterior  and  two 
lateral  ligaments  formed  from  the  pelvic  fascia,  and  a  superior  round  liga- 
ment consisting  of  the  remains  of  a  fetal  structure,  the  uraclius,  attached 
to  the  summit  of  the  organ.  There  are  also  five  false  ligaments, — two  ante- 
rior, two  lateral,  and  one  superior, — consisting  of  folds  of  peritoneum. 

Structure. — The  bladder  is  composed  of  four  coats,  viz.:  1.  External 
or  serous,  derived  from  the  peritoneum,  and  investing  the  posterior,  lateral, 
and  a  portion  of  the  superior  surfaces  of  the  organ.  2.  Muscular,  consist- 
ing of  three  layers,  external,  middle,  and  internal.  The  external,  or  longi- 
tudinal, layer  is  termed  the  detrusor  urince.  This  is  the  most  important 
of  the  three  layers,  and  is  arranged  in  fasciculi,  or  bundles  of  fibers.  These 
bundles  of  fibers  are  defective  at  certain  intervals,  which  accounts  for  the 
formation  of  saeculi  in  chronic  vesical  disease,  as  will  be  noted  later  on. 
The  middle  layer  consists  of  circular  fibers,  thickest  at  the  neck  of  the 
organ,  where  they  form  a  defective  muscular  ring  erroneously  termed  the 
sphincter  vesicce — the  false  sphincter  vesicse.  The  internal,  or  submucous, 
layer  is  the  thinnest  of  the  three,  and  consists  of  so-called  fibers,  part 
of  which  are  longitudinal  and  part  oblique.  Some  of  the  longitudinal 
fibers  constitute  the  muscles  of  the  ureters.  The  three  layers  of  muscular 
fibers  are  joined  by  fasciculi  and  act  as  a  single  muscle.  3.  Areolar,  or 
submucous.  This  coat  is  simply  a  thick  layer  of  areolar  tissue  between 
the  muscular  and  mucous  coats.     It  is  absent  at  the  trigone:    a  fact  of 

(732) 


EUPTUEE  OF  THE  BLADDEE.  733 

great  surgical  importance.  4.  Mucous.  This  coat  is  the  lining  of  the 
bladder.  It  is  thick,  smooth,  and  of  a  pale-rose  color.  It  is  abundantly 
supplied  with  mucous  glands.  It  is  continuous  with  the  lining  of  the 
ureters  and  pelvis  of  the  kidney,  the  urethra,  Cowper's  glands,  the  seminal 
vesicles,  and  vas  deferens.  The  epithelium  of  the  bladder  is  flattened,  and 
variable  in  size.  The  vascular  supply  is  abundant,  but  the  nerves  are  few 
in  number;   hence  the  bladder  is  quite  insensitive. 

On  the  internal  surface  of  the  base  of  the  bladder  is  the  trigone.  This 
is  a  triangular  space  bounded  at  its  base  by  the  orifices  of  the  ureters,  and 
at  its  apex  by  the  prostate.  In  this  situation  there  is  no  submucous  areolar 
tissue;  hence  the  readiness  and  impunity  with  which  the  bladder  may  be 
punctured  at  this  point.  At  the  apex  of  the  trigone  is  a  transverse  fold  of 
mucosa  termed  the  uvula  vesicce. 

Vessels  and  Nerves. — The  arteries  are  the  superior  vesical,  comprising 
three  or  four  small  twigs  from  the  hypogastric,  and  the  inferior  vesical 
from  the  internal  iliac.  The  veins  are  large  and  abundant,  forming  a 
plexus  around  the  vesical  neck  communicating  with  the  prostatic  and 
hemorrhoidal  plexuses.  The  nerves  are  derived  from  the  inferior  hypo- 
gastric plexus  and  the  third  and  fourth  sacral  nerves. 

EUPTUEE    OF   THE   BLADDEE. 

Eupture  of  the  u.rinary  bladder,  while  not  a  frequent  accident,  in  all 
Ijrobability  occurs  oftener  than  has  been  supposed.  Falls  or  blows  upon 
the  abdomen  are  often  productive  of  that  vague  class  of  injuries  desig- 
nated— most  often  in  the  patient's  death-certificate — as  "internal"  the  fatal 
element  of  which  injury  is  probably  often  a  peritonitis  due  to  traumatic 
rupture  of  the  bladder.  As  abdominal  surgery  progresses,  and  the  general 
practitioner  becomes  more  familiar  with  the  indications  and  technic  of 
celiotomy,  rupture  of  the  bladder,  in  all  probability,  will  be  found  to  be 
much  more  frequent  than  has  hitherto  been  believed. 

Etiology. — Predisposing  Causes. — Sex  and  age  are  the  most  impor- 
tant predisposing  causes.  Because  of  the  greater  activity  of  the  male,  and 
more  frequent  exposure  to  sources  of  mechanic  injury  and  strain,  rupture 
of  the  bladder  is  more  frequent  than  in  the  female.  In  288  cases,  only  48 
occurred  in  the  female. 

Obstruction  of  the  urinary  outflow  is  a  potent  predisposing  cause,  and 
the  conditions  giving  rise  to  such  obstruction  are  more  frequently  found 
in  the  male.  In  such  cases  the  vesical  walls  are  usually  diseased,  sacculi 
from  backward  pressure  becoming  the  most  important  pathologic  condition 
favoring  rupture. 

Age  has  much  to  do  with  the  causation  of  vesical  rupture.  It  occurs 
most  usually  between  twenty  and  forty  years  of  age,  because  at  this  period 
the  subject  is  most  exposed  to  sources  of  injury.  This  is  especially  true  of 
the  male  sex. 


734  DISEASES    OE    THE   UEINAEY   BLADDER. 

Drunkenness  has  been  advanced  as  another  predisposing  cause.  In 
most  cases  in  which  the  patient  is  intoxicated  sensibility  is  blunted  and 
the  function  of  micturition  is  liable  to  be  neglected,  the  bladder  becoming 
distended.  There  is  also  a  greater  liability  to  falls  and  blows  than  when 
the  subject  is  in  a  normal  condition. 

Exciting  Causes. — Falls  or  blows  upon  the  abdomen  when  the  blad- 
der is  distended  from  whatever  cause,  or  overdistension  from  obstruction 
of  the  viscus,  constitute,  in  general,  the  exciting  causes  of  vesical  rupture. 
Kicks  or  blows,  or  being  trodden  upon,  are  very  likely  to  result  in  vesical 
rupture  when  the  viscus  is  distended.  In  a  few  instances  rupture  of  the 
bladder  has  been  attributed  to  simple  concussion.  It  is  questionable 
whether  or  not  simple  overdistension  of  the  normal  bladder  can  produce 
rupture.  Cases  of  this  kind  have  been  recorded.  The  author,  however,  is 
seriously  inclined  to  doubt  their  authenticity.  It  is  generally  accepted  that 
excessive  muscular  action  in  the  presence  of  an  overdistended  bladder  may 
produce  rupture  of  the  viscus;  thus,  struggling  during  anesthesia,  strain- 
ing at  stool,  lifting  heavy  weights,  and  violent  efforts  at  micturition  have 
been  known  to  produce  the  accident.  In  the  female,  displacement  of  the 
gravid  uterus  has  been  known  to  cause  it. 

Morbid  Anatomy. — Of  322  cases  of  vesical  rupture  collected  by  Riv- 
ington,  152  were  simple  fatal  intraperitoneal  ruptures;  30  were  complicated 
intraperitoneal  ruptures  with  a  fatal  result;  90  were  extraperitoneal  rupt- 
ures, simple  and  complicated;  in  5  cases  the  location  of  the  rupture  was 
undetermined.  Simple  intraperitoneal  rupture  occurs  most  frequently,  the 
extraperitoneal  variety  being  usually  incidental  to  fracture  of  the  pelvic 
bones.  In  a  general  way,  the  extraperitoneal  rupture  is  not  so  quickly  fatal 
as  the  intraperitoneal,  which  is  a  noteworthy  point,  especially  when  it  is 
taken  into  consideration  that  the  extraperitoneal  variety  is  usually  com- 
plicated by  severe  crushing  injury  involving  the  pelvic  bones,  and  inci- 
dentally other  structures  and  organs. 

Location  and  Extent  of  Euptuee. — As  a  rule,  the  rupture  occurs 
on  the  posterior  surface  of  the  viscus.  The  rupture  is  exceptionally  less 
than  one  or  more  than  two  inches  in  length.  It  may  occur  in  any  location. 
Cases  have  been  recorded  in  which  the  vesical  rent  was  at  one  or  the  other 
side,  at  the  fundus,  or  in  the  vicinity  of  the  vesical  neck.  Very  small 
ruptures,  with  a  fatal  result,  have  been  recorded,  and  in  some  instances 
a  size  of  three  inches  or  more  in  length  has  been  attained. 

Symptoms. — The  symptoms  of  injury  vary  greatly  according  to  the 
circumstances  under  which  it  is  inflicted.  Obviously,  a  patient  who  is  pro- 
foundly inebriated  will  present,  for  the  time  being,  few  or  no  symptoms. 
Cases  are  on  record  in  which  a  drunken  individual  has  been  seriously  in- 
jured and  the  bladder  extensively  ruptured  without  symptoms,  so  far  as 
the  bladder  was  concerned,  for  some  time  after  the  injury.  In  cases  in 
which  the  rupture  is  slight  the  patient  may  pass  urine  containing  little 


EUPTUEE  OF  THE  BLADDEE.  735 

or 'no  blood,  and  no  special  symptoms  indicative  of  bladder-injury  occur, 
the  patient  dying  of  fatal  peritonitis,  which,  if  recognized,  is  attributed 
to  some  other  traumatic  accident  than  rupture  of  the  bladder.  In  some 
instances  the  patient,  whether  inebriated  or  not,  may  exhibit  little  or  no 
shock,  and  is  able  to  walk  for  some  time  after  the  accident.  Cases  have 
been  known  in  which  serious  symptoms  were  delayed  for  twenty-four  hours. 
As  a  rule,  severe  pain  and  symptoms  of  shock,  often  to  the  degree  of  com- 
plete collapse,  supervene  immediately  upon  the  infliction  of  the  injury. 
The  patient  may  complain  of  a  sensation  as  of  something's  bursting  in 
the  abdomen.  Locomotion  is  generally  impossible  for  the  time  being.  It 
is  an  unfortunate  fact  that  the  pain  and  symptoms  of  shock  are  likely  to 
pass  over  after  a  short  time,  leaving  the  patient  feeling  quite  comfortable. 
Pain  and  urgent  desire  to  urinate,  however,  soon  supervene,  the  attempts  at 
micturition  being  ineffectual  in  the  majority  of  instances.  As  a  rule,  the 
patient  is  able  to  expel  only  a  little  blood,  or  perhaps  a  small  quantity 
of  very  bloody  urine.  The  face  becomes  pale  and  contracted,  with  an  ex- 
pression of  extreme  anxiety.  Restlessness;  nausea,  perhaps  vomiting;  and 
extreme  thirst,  with  great  general  prostration  and  small,  rapid,  irregular 
pulse,  develop.  On  passing  the  catheter  nothing  is  obtained  save  more 
or  less  blood,  or  perhaps  a  small  quantity  of  urine.  The  catheter  may 
pass  through  the  rent  in  the  bladder  and  enter  the  abdominal  cavity,  or  it 
may  be  obstructed  in  the  vicinity  of  the  vesical  neck.  The  latter  is  espe- 
cially apt  to  be  the  case  in  extraperitoneal  rupture  with  fracture  of  the 
pelvic  bones.  Where  the  catheter  passes  into  the  peritoneal  cavity,  it 
may  sometimes  be  felt  through  the  abdominal  walls  with  such  distinctness 
as  to  immediately  establish  the  diagnosis.  As  a  diagnostic  test,  eight  or 
ten  ounces  of  warm,  mild  antiseptic  solution,  or,  better,  sterilized  water, 
should  be  injected  through  the  catheter.  If  no  rupture  in  the  bladder 
exists,  the  entire  quantity  will  return  through  the  catheter.  If  there  is  an 
aperture  in  the  wall  of  the  bladder,  only  a  portion  of  the  fluid  will  return. 

If  relief  is  not  afforded  peritonitis  develops  very  speedily;  the  abdomen 
becomes  distended  and  tender,  with  persistent  vomiting,  feebleness,  great 
irregularity  and  rapidity  of  pulse,  with  the  characteristic' rapid  chest-breath- 
ing of  peritonitis.  Pain  is  quite  severe,  and  in  some  instances  excruciating. 
A  useful  point  in  the  diagnosis  is  to  establish,  so  far  as  possible,  the  con- 
dition of  the  bladder  at  the  time  the  injury  was  received.  If  empty  when 
the  accident  occurred,  the  probabilities  are  largely  against  vesical  rupture. 
Another  important  point  is  the  fact  that  the  secretion  of  urine  may  be 
lessened,  or  cease  altogether,  as  a  result  of  abdominal  injury  in  which  the 
bladder  is  not  ruptured.  The  subsequent  course  of  the  case,  however,  clears 
up  the  diagnosis. 

Teeatment.  —  When  once  the  diagnosis  has  been  established  imme- 
diate celiotomy  is  indicated.  A  free  opening  into  the  abdominal  cavity  is 
usually  required  to  obtain  free  access  into  the  bladder.     If  necessary  to 


736 


DISEASES    OF    THE    UEINAKY    BLADDEE. 


divide  the  rectal  muscles  at  their  insertion  into  the  pnbes,  this  should 
be  done.  Free  exposure  of  the  bladder  is  a  sine  qua  non,  the  more  especially 
as  it  is  quite  easy  to  overlook  a  small  rent  in  the  viscus,  irrespective  of  the 
necessity  for  an  abundance  of  room  for  the  surgical  procedures  necessary 
for  the  closure  of  the  wound.  As  a  rule,  urine  mized  with  serum  and  blood 
escapes  through  the  incision  immediately  the  abdomen  is  opened.  Peter- 
son^s  rectal  bag  has  been  recommended  for  the  purpose  of  bringing  the 
bladder  more  distinctly  into  view.  The  fingers  of  an  intelligent  assistant, 
however,  are  usually  more  serviceable.  Where  the  rent  in  the  bladder  is 
low  down,  MacCormac  has  recommended  transverse  incisions  in  the  peri- 
toneal investments  of  the  bladder  as  jDermitting  the  viscus  to  be  raised  with 
greater  facility.  In  suturing  the  vesical  rent,  the  Lembert  suture,  or  some 
of  its  modifications,  should  be  used. 

Either  silk  or  catgut  may  be  used,  silk  being  preferred  by  most  opera- 


Fig.  150. — Method  of  suturing  bladder.     (After  MacCormac.) 


tors.  Interrupted  silk  sutures,  reinforced  by  continuous  chromicized  cat- 
gut, is  most  trustworthy.  The  silk  sutures  should  include  the  peritoneum 
and  muscular  wall  of  the  bladder  only;  penetration  of  a  single  suture 
through  the  mucous  membrane  of  the  vesical  cavity  is  likely  to  prove  fatal 
by  subsequent  leakage.  The  continuous  catgut  suture  may  partially  in- 
clude the  bladder-wall,  and,  being  brought  back  after  having  traversed  the 
entire  line  of  rupture,  should  be  made  to  include  the  peritoneum  only. 
When  sutured  in  this  way,  leakage  can  hardly  occur.  The  sutures  should 
be  tested  by  distending  the  bladder  with  sterilized  water.  The  abdomen 
should  be  thoroughly  flushed  throughout  with  sterilized  water  or  normal 
salt  solution.  It  is  wise  to  take  no  chances  of  the  urine's  having  become 
diffused  throughout  the  abdominal  cavity,  as  it  is  very  likely  to  do  soon 
after  its  escape  from  the  bladder.  Authorities  are  divided  on  the  question 
of  abdominal  drainage.     The  author  is  of  opinion,  however,  that  the  pro- 


FOEEIGN  BODIES  IN  AND  EXSTKOPHY  OF  THE  BLADDER.      737 

fession  should  be  united  upon  the  advisability  of  drainage.  The  rule  has 
been  formulated:  "When  in  doubt^  drain."  We  must  necessarily  always 
be  in  doubt  in  rupture  of  the  bladder.  MacCormac  and  others  have  ad- 
vised against  urethro-vesical  drainage.  This  does  not  seem  wise.  Drainage 
for  the  first  few  days^  if  carried  out  with  antiseptic  precautions,  is  not  only 
safe,  but  the  only  protection  possible  against  strain  upon  the  vesical  sutures. 
Even  though  the  suturing  be  not  technically  perfect,  continuous  siphon 
drainage  may  obviate  leakage  until  Nature  has  closed  the  vesical  wound. 

FOREIGN  BODIES  IN  THE  BLADDER. 

Foreign  bodies  in  the  bladder  are  of  importance  chiefly  because  of  their 
relation  to  urinary  calculus.  The  peculiar  psychopathic  condition  that  im- 
pels patients  to  introduce  foreign  bodies  into  the  urethra  usually  leads  to 
secretiveness,  until  a  calculus  has  formed  about  the  foreign  body,  with  re- 
sultant symptoms  that  necessitate  consulting  the  surgeon.  All  sorts  of  for- 
eign bodies  have  been  introduced  in  this  manner:  a  point  that  will  be  ex- 
patiated upon  under  the  head  of  "Urinary  Calculus."  Where  there  is  positive 
knoAvledge  of  the  existence  of  a  foreign  body,  as  in  the  case  of  instruments 
broken  off  in  the  bladder  by  the  surgeon,  or  in  cases  in  which  the  patient  is 
reliable,  and  is  absolutely  certain  that  a  foreign  body  has  escaped  the  fingers 
and  passed  into  the  urethra,  immediate  operation  is  demanded.  Careful 
exploration  of  the  bladder  with  the  searcher  and  cystoscope  will  usually 
establish  the  diagnosis.  The  operation  par  excellence  for  the  removal  of  for- 
eign bodies  is  suprapubic  section. 

EXSTROPHY    OF   THE   BLADDER. 

Exstrophy  of  the  bladder,  while  rare,  is  the  most  frequent  of  the 
congenital  defects  of  the  organ.  The  condition  is  probably  due  to  arrested 
development  of  the  sides  of  the  uro-genital  canal,  which  fail  to  fuse  in  the 
median  line  and  consequently  do  not  form  the  anterior  wall  of  the  bladder 
and  the  median  portion  of  the  anterior  abdominal  wall.  There  is  also  de- 
fective development  or  absence  of  the  pubic  symphysis.  Thiersch  holds  that 
the  condition  is  due  to  atresia  of  the  urinary  way,  with  subsequent  rupture 
of  the  bladder  and  its  abdominal  envelopes.  As  a  consequence  of  this 
defective  support  and  covering,  the  posterior  vesical  wall  protrudes  an- 
teriorly through  the  aperture;  its  mucous  membrane,  being  unprotected, 
becomes  the  seat  of  chronic  inflammation,  and  is  usually  covered  with 
mucus  or  muco-pus,  with  perhaps  more  or  less  phosphatic  deposit. 

Exstrophy  is  associated  with  the  extreme  degree  of  epispadias.  The 
prostate  is  either  rudimentary  or,  as  a  distinct  body,  absent.  The  scrotum 
may  be  absent,  in  which  instance  the  testes  are  found  in  the  crural  canal. 
Inguinal  hernia  often  exists  upon  both  sides.  The  exposure  of  the  mucous 
membrane  of  the  bladder  to  mechanic  irritation  and  to  the  air  gives  rise 
to  great  annoyance  from  the  chronic  inflammation  thereby  induced.     The 


738 


DISEASES    OF    THE    URINAET   BLADDER. 


urine  is  ammoniacal,  and  the  integument  in  the  vicinity  of  the  protruding 
bladder  becomes  reddened  and  excoriated,  and  of  a  quasimucous  character. 
Patients  affected  with  exstrophy  usually  suffer  from  malnutrition  and  im- 
perfect development  in  other  directions. 

Treatment. — The  treatment  of  ectopia  vesicse,  or  exstrophy  of  the 
bladder,  is  at  best  quite  unsatisfactory.  Even  after  the  most  successful 
plastic  operation  it  is  usually  necessary  for  the  patient  to  wear  an  appliance 
for  the  collection  of  the  urine.  The  most  that  can  be  hoped  for  is  to  so 
cover  in  the  bladder  as  to  protect  the  mucous  membrane  of  the  posterior 
wall  of  the  viscus  from  exposure  and  friction.  Under  ordinary  circum- 
stances— always  in  severe  types  of  exstrophy — it  is  impracticable  to  keep 
the  clothing  clean  or  prevent  irritation  of  the  surrounding  tissues  by  the 
urine  by  any  sort  of  appliance.  Of  all  the  plastic  operations  that  have  thus 
far  been  devised,  the  most  popular  and  successful  is  Wood's.    In  this  opera- 


Fig.  151. — Wood's  method.    Out- 
line of  flaps. 


Fig.  152. — The  same  after  inser- 
tion of  sutures. 


tion  the  flaps  are  so  arranged  that  there  is  a  double  layer  of  tissue  in  the 
new  anterior  wall  of  the  abdomen.  The  epidermis  of  one  flap  is  directed 
to  the  interior  of  the  bladder,  while  the  other  flap  is  laid  over  this,  with 
the  raw  surfaces  in  contact.  The  flrst  of  these  flaps,  in  which  the  hair- 
follicles  have  previously  been  destroyed  to  prevent  subsequent  accumula- 
tion of  phosphates  upon  the  hair  in  the  bladder,  is  reflected  downward  from 
the  abdominal  wall;  if  necessary,  from  a  point  above  the  umbilicus.  This 
flap  should  have  as  wide  a  pedicle  as  practicable,  and  should  come  well 
down  to  the  root  of  the  penis,  and  sufficiently  far  outward  upon  each  side 
to  come  in  contact  with  the  edges  of  the  opening,  there  being  at  the  same 
time  enough  flap  to  allow  for  shrinkage.  The  inferior,  or  lateral,  flaps 
are  taken  from  either  side,  and  should  be  large  enough  to  cover  in  the 
entire  surface  of  the  superior  flap  and  extend  beyond  it  above  and  laterally 
upon  the  raw  surfaces  left  by  the  elevation  of  the  several  flaps.  When 
these  flaps  are  united  by  silk-worm  gut  and  chromicized  catgut,  a  small 


CYSTITIS.  739 

opening  is  left  corresponding  to  the  dorsum  of  the  penis.  The  flaps  in 
the  middle  line  should  be  united  by  harelip-pins  and  the  figure-of-eight 
suture^  with  such  intermediate  sutures  of  silk-worm  gut  and  catgut  as  may 
be  necessary  to  obtain  perfect  coaptation. 

In  Thiersch's  method  a  new  urethra  is  first  formed  by  reflecting  flaps 
of  skin  and  mucous  membrane  from  the  rudimentary  penis.  In  this  method 
a  certain  degree  of  urinary  control  is  sometimes  secured.  The  operations 
for  the  treatment  of  epispadias  have  been  considered  in  detail  in  a  preceding 
chapter. 

Maydl's  method,  the  latest  operation  for  ectopia  vesicae,  comprises  the 
transplantation  of  a  portion  of  the  bladder-wall,  containing  the  orifices  of 
the  ureters,  into  the  sigmoid  flexure  of  the  colon.  If  the  patient  survives 
this  formidable  operation,  he  is  exposed  to  renal  infection,  which  usually 
occurs  and  inevitably  proves  fatal.  Successful  cases  have  been  reported, 
but  the  advisability  of  the  operation  is  by  no  means  established.  Time  will 
doubtless  demonstrate  its  true  value,  however. 

CYSTITIS. 

Idiopathic  inflammation  of  the  bladder  is  a  very  rare  affection;  so 
rare,  indeed,  that,  when  cystitis  occurs,  its  secondary  character  is  imme- 
diately to  be  inferred  and  the  primary  condition  carefully  sought  for. 
Some  authorities  go  so  far  as  to  claim  that  idiopathic  cystitis  is  an  unknown 
disease;  this  statement,  however,  is  not  only  an  exaggeration,  but  incon- 
sistent with  our  modern  ideas  of  etiology  and  pathology.  It  is  easy  to  under- 
stand why  idiopathic  cystitis  should  be  rare.  The  protected  situation  and 
uniform  temperature  of  the  organ  and  its  being  constantly  bathed  in  a  warm, 
aseptic,  and  relatively-bland  fluid — the  urine- — ^must  necessarily  protect  it 
to  a  great  extent  from  the  ordinary  causes  of  inflammation.  In  general, 
cystitis  means  infection,  either  primary  or  secondary,  from  some  source  or 
other.     Cystitis  from  this  cause  is  very  common. 

Inflammation  of  the  bladder  occurs  in  two  forms:  the  acute  and  chronic. 

Acute  Cystitis. — Acute  cystitis  implies  an  acute  inflammation  affect- 
ing the  mucosa  of  the  body  and  fundus  of  the  bladder. 

Etiology. — Acute  cystitis  occasionally  appears  to  be  due  to  exposure 
to  cold  and  wet,  especially  when  such  exposure  is  combined  with  dietetic 
or  alcoholic  excess,  the  gouty  or  rheumatic  diathesis,  and  latent  infection. 
There  is  great  difference  of  opinion  as  to  the  importance  of  exposure  in  the 
etiology  of  cystitis.  The  author's  own  view  is  that,  while  exposure  is  an 
important  etiologic  factor,  it  is  never  operative  in  the  absence  of  infection. 
Bacteriologic  investigation  would  probably  prove  the  truth  of  this  in  every 
instance.  Latent  mild  infection  of  the  bladder  is  much  more  frequent  than 
is  generally  supposed,  and  exposure  to  cold  or  wet  in  combination  with  the 
other  etiologic  factors  mentioned — or  without  them,  for  that  matter — may 
so  lessen  vital  resistance  in  the  vesical  mucosa  that  rapid  and  vicious  germ- 


740  DISEASES    OF    THE    URINAET   BLADDEE. 

evolution  occurs.  A  foundation  for  cystitis^  in  the  form  of  chronic  in- 
fection, usually  exists  where  exposure  causes  acute  cystitis.  It  is  further- 
more probable  that  in  a  large  proportion  of  cases  that  are  supposed  to  be 
acute  cystitis,  even  where  some  source  of  infection  is  known  to  exist,  the 
diagnosis  is  incorrect,  the  parts  in  and  about  the  true  vesical  neck — i.e., 
the  deep  urethra — being  the  true  seat  of  the  inflammation.  The  most  fre- 
quent cause  of  acute  cystitis  is  gonorrheal  infection,  the  irritation  produced 
by  harsh  treatment  of  gonorrhea  coming  next  in  order.  Even  in  cases  of 
infection  the  treatment  is  frequently  primarily  responsible  for  the  vesical 
complication,  and  this  is  due  to  negligence  on  the  part  of  the  surgeon  in 
not  a  few  instan'ces.  The  gonorrheal  patient  is  allowed  to  go  about  as 
recklessly  as  when  in  his  normal  condition,  the  most  active  exercise  being 
indulged  in,  in  many  cases,  without  a  word  of  warning  from  the  medical 
attendant.  As  a  result,  an  extension  of  the  urethral  inflammation  occurs, 
and  the  patient  is  attacked  by  some  such  complication  as  cystitis,  pros- 
tatitis, or  epididymitis.  The  patient  is  also  provided  with  a  syringe  and 
an  injection  of  greater  or  less  strength  without  the  slightest  instruction  as 
to  their  proper  use.  As  a  consequence,  the  patient  forces  the  fluid  down 
to  the  neck  of  the  bladder,  and  often  drives  a  portion  into  the  viscus  itself. 
The  injection,  if  strong,  may  set  up  chemic  inflammation  of  the  bladder, 
or,  independently  of  its  strength,  may  produce  still  more  serious  results  by 
acting  as  the  carrier  of  mixed  infection  to  the  vesical  mucosa.  In  this 
manner  a  very  mild  injection  may  do  more  serious  damage  than  one  that 
is  comparatively  strong,  the  latter  being  apt  to  destroy  the  specificity  of 
the  gonorrheal  virus  and  produce  injury  by  its  chemic  action  alone. 

ISTotwithstanding  what  has  been  said  regarding  the  importance  of  gon- 
orrhea in  the  etiology  of  acute  cystitis,  the  author  believes  that  the  infec- 
tion rarely  produces  inflammation  of  the  bladder  proper.  Most  cases  diag- 
nosed as  acute  gonorrheal  cystitis  are  really  instances  of  acute  follicular 
prostatitis.  The  relative  immunity  from  infection  by  the  gonococcus  char- 
acterizing pavement-epithelium  explains  the  resistancy  of  the  vesical  mucosa 
to  gonorrheal  infection.  Acute  generalized  cystitis  of  a  serious  character 
does  sometimes  occur  as  a  result  of  gonorrhea,  but  the  "mixed"  element  of 
the  infection  rather  than  the  gonococcus  is  responsible  for  it. 

Mechanic  injury  is  often  responsible  for  acute  cystitis,  the  rude  passage 
of  instruments  being  a  not  infrequent  cause.  In  some  cases  of  gonorrhea 
in  which  it  is  found  necessary  to  pass  the  catheter  acute  cystitis  occurs. 
Even  when  used  with  the  greatest  care  instruments  cannot  be  passed  into 
the  bladder  in  acute  gonorrhea  or  in  cases  of  gleet  in  which  the  mixed  in- 
fection is  still  virulent  without  incurring  the  danger  of  conveying  infection 
into  the  bladder.  This  is  a  point  that  is  worthy  of  the  most  serious  consid- 
eration. 

The  importance  of  conjoined  instrumental  trauma  and  infection  is 
presented  by  a  recent  writer  as  follows: — 


ETIOLOGY    OF    ACUTE    CYSTITIS.  741 

Cystitis  often  develops  after  frequent  catheterism  in  women.  This,  Avhile  ordi- 
narily due  to  infection,  has  been  attributed  to  injuries  produced  in  passing  the 
catheter  rather  than  the  use  of  a  dirty  instrument,  because  occurring  in  cases  where 
the  catheters  have  been  sterilized  and  kept  with  great  care  in  an  antiseptic  solution 
and  used  principally  by  the  nurse.  Cystitis  sometimes  develops  in  spite  of  asepsis. 
The  cystitis,  therefore,  would  seem  to  be  due  to  traumatism,  for  in  these  cases  not 
only  had  asepsis  of  the  catheters  been  looked  after,  but  the  meatus  had  been  carefully 
cleaned  before  their  introduction.^ 

Noble  emphasizes  the  fact  that  all  who  have  devoted  special  attention 
to  catheterization  as  a  cause  of  cystitis  in  parturient  women  are  aware  that 
there  is  no  surer  way  to  cause  cystitis  than  to  catheterize  without  full  anti- 
septic precautions: — 

The  catheter  should  never  be  passed  without  exposure  and  cleansing  of  the 
meatus  urinarius.  The  cleansing  should  be  done  with  bichlorid  solution  1  to  1000, 
and  a  sterilized  catheter  passed  under  the  guidance  of  the  eye.  Because  of  the 
facility  with  which  glass  catheters  can  be  sterilized  by  boiling,  these  are  to  be 
preferred.  If  a  soft-rubber  catheter  is  used,  this  should  be  boiled  for  five  minutes 
immediately  before  being  used.  A  glass  catheter  can  be  passed  without  any  lubri- 
cating material,  if  it  is  dipped  in  the  bichlorid  solution  and  introduced  wet.  If  a 
lubricant  is  used,  the  best  is  boroglycerid.- 

Crushing  injuries  of  the  pelvis,  with  involvement  of  the  vesical  walls, 
and  blows  upon  the  hypogastrium  occasionally  cause  acute  cystitis.  Opera- 
tions upon,  or  explorations  of,  the  bladder  for  stone  or  other  morbid  con- 
ditions may  also  give  rise  to  acute  inflammation.  The  rough  jolting  experi- 
enced by  patients  with  vesical  calculus  while  riding  over  rough  pavements 
is  liable  to  cause  an  acute  exacerbation  of  the  low  grade  of  inflammation 
always  attendant  upon  such  cases.  This  result  of  trauma  is  easily  explained. 
The  bladder  being  already  infected,  the  germs  attack  with  great  avidity  any 
areas  of  vesical  mucosa  the  vitality  of  which  has  been  already  impaired  by 
the  injury. 

It  has  apparently  been  established  that  the  bladder  may  be  infected 
transperitoneally,  as,  for  example,  from  the  rectum  or  other  portion  of  the 
intestinal  tract.  The  author  has  seen  such  a  case  of  acute  cystitis  apparently 
due  to  infection  from  a  septic  uterus.  Such  drugs  as  cantharides  and  tur- 
pentine in  large  doses  may  cause  acute  cystitis  attended  by  priapism  and 
other  evidences  of  inflammation  of  the  genito-urinary  tract. 

Highly-concentrated  acid  urine  is  an  alleged  cause  of  acute  inflamma- 
tion; but  that  it  alone  can  cause  such  a  condition  is  doubtful.  It  may,  how- 
ever, lay  the  foundation  for  chronic  cystitis.  The  author  desires  to  state  his 
belief  that  acid  urine  alone,  however  long  it  may  continue,  never  causes  either 


^Walker,  New  York  Medical  Journal,  March  19,  1898. 
-  Gaillard's  Medical  Journal,  April,  1898. 


743  DISEASES    OF    THE    UEINAET   BLADDEE. 

acute  or  chronic  cystitis,  but  merely  lays  the  foundation, — i.e.,  prepares  the 
soil, — infection  does  the  rest.  All  of  the  clinical  experience  of  the  past  is 
but  so  much  rubbish,  worthy  only  of  the  dead-lumber  room,  so  far  as  this 
particular  etiologic  factor  is  concerned.  The  most  important  point  to  be 
remembered  in  the  etiology  of  cystitis — acute  and  chronic — is  that  conges- 
tion forms  a  constant  invitation  to  bacterial  infection,  with  consequent  acute 
inflammation.  Congestion  plays  the  preparatory  role,  no  matter  what  the 
exciting  cause  may  be — ^save  in  the  case  of  immediate  infection  of  a  healthy 
bladder  by  septic  instrumentation. 

Acute  cystitis,  irrespective  of  its  cause,  may  terminate  in  the  chronic 
form  of  the  disease. 

Morbid  Anatomy. — The  morbid  appearances  of  the  bladder  in  acute 
cystitis  vary  according  to  the  extent  and  character  of  the  inflammation. 
Pathologically,  the  disease  may  involve  (1)  the  mucosa  alone,  (2)  the  in- 
terstitial and  muscular  tissues,  and  (3)  the  pericystic  tissues — cellular  and 
peritoneal. 

In  the  superficial,  or  catarrhal,  variety  the  mucous  membrane  is  thick- 
ened and  reddened,  with  prominent  vessels  ramifying  upon  its  surface. 
Edema  and  small  extravasations  are  often  prominent.  In  some  cases  a 
croujDOUs  exudate  forms  a  mold  of  the  mucous  membrane,  of  greater  or  less 
extent,  and  this  comes  away  in  shreds  or  coinplete  casts  of  the  bladder — 
membranous  cystitis.     Erosions  or  even  ulcers  may  be  found. 

When  the  process  extends  to  the  interstitial  tissue,  small  abscesses  are 
likely  to  form.  Permanent  thickening  of  the  vascular  walls  may  follow. 
The  process  may  extend  to  the  peritoneum  and  produce  peritonitis — pelvic 
or  general. 

Membranous  or  croupous  cystitis  is  mostly  found  in  women.  Stein 
asserts  that  it  is  most  often  associated  with  pregnancy  or  uterine  disease.^ 
The  casts  may  embrace  the  entire  mucosa  or  even  a  portion  of  the  mus- 
cular wall.  As  a  rule,  however,  only  the  epithelial  layer  of  the  mucosa  is 
involved  and  shed  with  the  exudative  cast.  Walls  relates  two  interesting 
cases  of  exfoliating  cystitis.  Both  resulted  from  retroversion  of  the  gravid 
uterus.  The  first  case  came  under  treatment  in  the  fourth  month  of  preg- 
nane}^, the  second  after  abortion  had  taken  place.-  The  author  has  recently 
seen  a  most  interesting  case  of  croupous  cystitis  in  the  practice  of  Dr.  E.  C. 
Christie,  of  Chicago. 

Bacteria  and  cocci  of  various  kinds  are  found  in  the  cystitic  urine,  the 
bacterium  coli  commune  being  the  principal  micro-organism  that  is  under 
suspicion  in  the  etiologic  deductions  of  many  laboratory-workers. 

In  some   cases   of  acute  septic   inflammation   of  the  bladder,   actual 


^  "Diseases  of  the  Female  Bladder." 
'British  Medical  Jounial.  Mav  1,  1897. 


SYMPTOMS    OF   ACUTE    CYSTITIS.  743 

sloughing  of  the  mucosa  with  a  variable  amount  of  the  muscular  coat  oc- 
curs— gangrenous  cystitis.  This  variety,  like  the  true  exfoliative  variety, 
is  due  to  disturbance  of  the  circulation  from  long-continued  pressure  asso- 
ciated with  microbic  infection.  In  the  gangrenous  variety  sudden  relief  of 
pressure,  as  in  evacuation  of  the  bladder  after  prolonged  retention,  not  only 
produces  sudden  and  destructive  determination  of  blood  to  the  vesical  walls, 
but  lessens  resistance  to  pathogenic  microbes. 

Symptoms.  —  The  symptoms  of  acute  cystitis  are  quite  definite  and 
severe  in  extreme  cases,  and  sufficiently  characteristic  in  all  grades  of  acute 
inflammation.  If  the  attack  be  violent,  it  is  ushered  in  by  rigors,  followed 
by  fever  and  more  or  less  perspiration.  Pain  is  a  prominent  symptom,  and 
is  referred  to  the  hypogastrium,  perineum,  sacrum,  and  often  to  the  penis, 
groins,  and  anterior  surface  of  the  thighs.  Pressure  above  the  pubes  and 
with  the  finger  in  the  rectum  elicits  considerable  tenderness.  In  a  general 
way,  the  attitude  and  expression  of  the  patient  suggest  acute  peritonitis, 
the  thighs  being  flexed  upon  the  abdomen,  and  the  expression  of  the  face 
one  of  great  anxiety.  Like  all  abdominal  inflammations,  acute  cystitis  is 
attended  by  great  depression  and  profound  constitutional  'disturbance,  as 
evidenced  by  elevation  of  temperature,  and  later  on  by  asthenia.  Urina- 
tion is  frequent  and  painful,  strangury  being  marked,  and  evacuation  of 
the  bladder  productive  of  no  relief.  The  urine  is  high-colored,  bloody  at 
first,  and,  in  a  short  time,  purulent.  Later  on  it  presents  a  shreddy  ap- 
pearance, and  is  mixed  with  ropy  mucus.  Epithelium  is  always  very  abun- 
dant. In  rare  cases  distinct  membranous  casts  of  the  vesical  mucosa — 
either  entire  or  fragmentary — are  found  in  the  urine.  Occasionally,  casts 
composed  entirely  of  muco-pus  with  a  little  fibrin  are  thrown  off.  These 
are  transitory  and  must  not  be  mistaken  for  the  true  exfoliative  variety 
of  cystitis,  in  which  the  structure  of  the  mucosa,  and  perhaps  the  muscular 
wall,  is  exfoliated.  If  sloughing  occurs,  a  gangrenous  odor  is  perceptible 
in  the  voided  urine.  In  severe  cases  the  patient  becomes  asthenic  and 
sinks  into  the  typhoid  condition,  with  dry,  brown  tongue,  delirium,  and, 
if  kidney  complications  exist,  uremic  coma.  Death  in  from  one  to  two 
weeks  is  by  no  means  unusual,  especially  when  the  acute  inflammation  is 
superadded  to  chronic  cystitis  or  is  the  result  of  operations  upon  the  blad- 
der. Extension  upward,  with  resulting  acute  pyelonephritis,  is  often  the 
cause  of  death.  If  recovery  from  the  acute  symptoms  ensues,  the  inflam- 
mation is  always  quite  liable  to  become  subacute  or  chronic,  complete  re- 
covery being  rather  exceptional.  Abscess  of  the  bladder-walls,  pericystic 
abscess,  and  infiltration  of  urine  sometimes  occur.  These  conditions  prove 
fatal  in  the  majority  of  cases.  Fatal  diffuse  peritonitis  is  also  occasionally 
seen. 

According  to  Hutinel,  cystitis  from  colon  bacilli  in  children  is  gen- 
erally ushered  in  by  fever  of  irregular  type,  followed  speedily  by  frequent 
and  painful  urination,  often  attended  by  more  or  less  blood.     The  urine 


744  DISEASES    OF    THE    UEINARY   BLADDEE. 

contains  considerable  muco-pus,  with  epithelial  and  pus-cells,  and  quan- 
tities of  bacterium  coli.^ 

Treatment.— T'he  first  and  most  essential  point  is  to  secure  perfect  rest 
in  the  recumbent  position.  Pain  and  strangury  should  be  relieved  by  mor- 
phia or  other  preparations  of  opium,  rest  for  the  bladder  being  at  the  same 
time  secured  by  the  consequent  diminution  in  the  frequency  of  micturition. 
Anodynes  should  usually  be  given  by  suppository.  The  nearer  such  drugs 
as  opium  can  be  brought  to  the  affected  part,  the  better — especially  is  this 
true  of  pelvic  inflammation  in  both  male  and  female.  Leeches  to  the  peri- 
neum and  hypogastrium  seem  to  be  beneficial  in  some  cases;  they  should 
be  followed  by  large  poultices  of  hot  linseedmeal  or  slippery  elm  sprinkled 
with  laudanum,  which,  as  Hilton  has  shown,  is  of  benefit  when  applied  in 
this  manner  for  internal  inflammations.-  An  ointment  containing  the  ex- 
tract of  belladonna,  gr.  x;  extract  of  aconite-root,  gr.  x;  and  menthol,  oj, 
to  the  ounce  of  lanolin,  continuously  applied  is  highly  beneficial.  This 
formula  is  so  useful  that  the  author  has  no  hesitancy  in  commending  it  as 
the  anodyne  application  par  excellence.  Prolonged  hot  sitz-baths  are  of  the 
greatest  service;  but,  if  it  be  impracticable  to  use  them,  heat  may  be 
applied  to  the  perineum  and  hypogastrium  by  means  of  the  hot-water  bag 
or  coil.  A  mercurial  purgative  is  always  indicated  at  the  beginning  of 
sthenic  cases,  but,  later  on,  the  bowels  should  be  evacuated  by  daily  enemata. 
Wlien  the  fever  is  high,  aconite,  veratrum  viride,  antimony,  and  the  coal-tar 
series  are  useful  drugs.  Hyoscyamus  is  frequently  of  service.  It  may  be 
combined  with  morphia  in  suppositories.  Diluents  should  be  freely  given. 
The  sine  qua  non  is  pure  water  in  large  amount.  Distilled  water  answers 
the  indications  very  well.  The  natural  lithia-waters  are  all  useful.  Where 
lithia  is  especially  indicated,  Sanders's  Garrod  Spa  is  the  best  water  that  the 
author  has  tried.  It  contains  a  definite  and  large  quantity  of  the  salts  of 
lithium  in  combination  with  potassium  salts.  The  dosage  of  lithium  in  this 
water  being  known,  it  thereby  has  a  manifest  advantage  over  the  natural 
waters. 

Demulcent  drinks  are  useful,  their  composition  being  a  matter  of  slight 
importance.  Acacia,  or  barley-water,  linseed,  and  slippery-elm  tea  are  all 
useful,  the  selection  being,  in  a  measure,  a  matter  of  taste.  The  citrate  or 
acetate  of  potassium  may  be  added  to  these  drinks  with  advantage.  The 
oil  of  eucalyptus  and  salol  in  combination  are  often  of  great  value  in  acute 
cystitis.  These  remedies  are  of  especial  value  in  the  catheter-cystitis  of 
parturient  women  and  following  operations  about  the  female  genito-urinary 
organs.     Pichi  and  saw  palmetto  are  also  valuable. 

An  excellent  formula  for  administration  in  acute  cystitis  is  the  fol- 
lowing:— 


^Eevue  International  de  Medecine  et  de  Chirurgie,  volume  vii,  1897. 
-  "Eest  and  Pain." 


CHEONIC    CYSTITIS.  745 

IJ  Potassii  acetat §1. 

Ext.  buchu  fl 81. 

Spt.  aetheris  nit SI- 

Codein.   sulph gr.  iv. 

Infus.  trit.  repent q-  s.  ad  Oj. 

M.     Sig.:    §ss  every  three  hours. 

As  the  acute  symptoms  subside,  buchu,  pareira  brava,  uva  ursi,  trit- 
icum  repens,  and  chimaphila  in  the  form  of  an  infusion  are  all  serviceable 
in  different  cases.  Later  on,  sandal-wood,  copaiba,  and  cubebs  are  indi- 
cated. 

Instrumentation  should,  in  general,  be  avoided,  but,  if  retention  occurs, 
catheterism  becomes  necessary.  A  small,  soft,  velvet-eyed  catheter  should 
be  introduced  and  the  urine  withdrawn.  In  such  cases  the  surgeon  should 
seize  the  opportunity  to  irrigate  the  bladder  after  its  evacuation.  A  hot 
solution  of  potassium  permanganate,  1  to  10,000;  bichlorid  of  mercury,  1 
to  30,000;  boric  acid  or  sodium  biborate  may  be  used  for  this  purpose.  The 
bichlorid  is  of  especial  value  in  cases  dependent  upon  gonorrheal  infec- 
tion. After  thorough  irrigation  an  ounce  or  two  of  a  2-per-cent.  solu- 
tion of  cocain  containing  about  5  to  10  grains  of  the  muriate  of  morphia 
should  be  injected.  The  patient  should  hold  this  in  the  bladder  as  long 
as  possible.  Great  relief  of  pain  and  strangury  is  thereby  obtained.  It  is 
hardly  necessary  to  state  that  this  should  not  be  done  if  there  is  any  sus- 
picion of  a  breach  of  continuity  of  the  vesical  mucosa. 

If  the  typhoid  condition  supervenes,  stimulants — quinin  and  digitalis 
— are  indicated. 

The  diet  in  acute  cystitis  should  consist  solely  of  milk.  The  general 
hot  bath  is  required  at  frequent  intervals,  both  for  its  sedative  effect  and  to 
relieve  the  kidneys  of  their  labors  so  far  as  possible.  Acute  cystitis  often 
occurs  where  there  is  ample  reason  for  suspicion  as  to  the  condition  of  the 
kidneys,  if  not  positive  knowledge  of  the  existence  of  renal  disease. 

Cheonic  Cystitis.- — Chronic  cystitis  has  been  described  by  some  au- 
thorities under  the  title  of  "irritable  bladder."  This  term  is  misleading  as 
applied  to  cystitis.  Obviously,  an  inilamed  bladder  is  irritable,  but  it  by 
no  means  follows  that  an  irritable  bladder  is  necessarily  inflamed.  The 
term  irritable  bladder  should  therefore  be  reserved  for  the  description  of 
an  affection,  to  be  hereafter  described,  that  is  essentially  different  from 
chronic  cystitis. 

Etiology. — The  causes  of  chronic  cystitis  are  chiefly  mechanic,  although 
it  may  be  traced  to  chemic  irritation  in  a  small  proportion  of  cases.  Yery 
often  the  affection  is  dependent  upon  a  combination  of  chemic,  mechanic, 
and  infectious  causes,  as  seen  in  vesical  calculus,  in  which  we  have  to  con- 
sider, not  only  the  irritation  produced  by  the  stone,  but  also  that  excited 
by  ammoniacal  urine  due  to  the  evolution  of  micro-organisms.  The 
mechanic  causes  of  chronic  cystitis  may  be  resolved  into  three  principal 


746  DISEASES    OF    THE    UEINAKY    BLADDEE. 

classes,  namely:  (1)  those  involving  urinary  obstruction  or  urinary  stagna- 
tion, (2)  those  involving  foreign  bodies  or  growths  in  the  bladder,  and  (3) 
those  in  which  foreign  material  coming  down  from  the  kidneys  produces 
chronic  inflammation  of  the  bladder.  Often  the  conditions  present  in  the 
three  classes  are'  blended  together.  Congestion,  of  the  bladder-walls  is  an 
all-important  factor  in  every  case.  Among  the  causes  included  in  the  first 
class  of  cases  may  be  mentioned  those  of  urethral  stricture,  tumors  and  ab- 
scesses of  the  urethra,  prostatic  tumors  and  hypertrophy,  prostatic  or  ure- 
thral calculus,  tumors  external  to  the  urethra.,  and  foreign  bodies  in  the 
urethra. 

-  In  the  second  class  come  calculi  of  the  bladder  and  the  various  forms 
of  vesical  tumor.  Foreign  bodies,  such  as  pieces  of  catheter  or  other  sur- 
gical instruments,  and  various  substances  surreptitiously  introduced  by  the 
patient  are  frequent  causes  of  cystitis.  Stagnation  and  retention  of  urine 
due  to  vesical  paralysis  or  atony  is  an  occasional  cause. 

In  the  third  class  we  have  a  discharge  of  pus  or  other  irritating  mate- 
rial into  the  bladder;  thus,  in  pyelitis  we  have  pus  from  the  pelvis  of  the 
kidney;  in  oxaluria  crystals  of  oxalate  of  lime;  and  in  uricemia  or  gravel 
minute  particles  of  urates,  all  of  which  produce  vesical  irritation  and,  later 
on,  chronic  inflammation.  Abscesses  in  the  vicinity  of  the  bladder  may 
open  into  that  viscus  and  infect  it,  thus  exciting  inflammation.  This  is  seen 
especially  in  women,  in  whom  pelvic  abscesses  are  so  frequent.  Diseases  of 
the  rectum  and  anus  are  apt  to  excite  cystitis,  both  directly  and  reflexly. 
Pathogenic  microbes  may  pass  from  the  intestines,  and  especially  from  the 
rectum,  to  the  bladder.  Highly-concentrated  urine  is  apt  to  lead,  first,  to 
vesical  irritability,  and  finally — probably  through  the  medium  of  infection 
— to  chronic  cystitis.  Infection  from  the  rectum  via  a  recto-vesical  or  ure- 
thro-rectal  fistula  is  an  occasional  cause  of  chronic  cystitis. 

The  author  desires  to  reiterate  his  belief  that  acidity  of  the  urine 
per  se  never  injures  the  normal  bladder.  The  urine  that  is  given  credit  for 
producing  cystitis  is  highly  acid,  it  is  true,  but  this  hyperacidity  is  not  the 
cause  of  the  cystitis.  The  irritation  produced  b}^  such  urine  is  due  to  the 
crystals  of  uric  acid,  oxalate  of  lime,  or  the  urates  that  it  contains,  and  not 
to  an  excess  of  sodium  biphosphate — the  salt  upon  which  normal  urinary 
acidity  depends.  The  concentration,  not  the  acidity,  of  urine  is  the  pathog- 
enic property  to  be  considered  in  the  etiology  of  cystitis.  Even  germs  do 
not  always  inflame  the  bladder.  The  hacierium  coli  commune  sometimes 
invades  the  bladder  in  follicular  enteritis,  without  producing  cystitis.  This 
is  especially  apt  to  occur  in  children. 

Chronic  cystitis  is  often  the  continuation  of  the  acute  form  of  the  dis- 
ease; hence  all  the  causes  of  acute  cystitis  are  etiologic  factors  in  the  chronic 
variety.  The  most  important  factor  in  the  etiology  of  chronic  cystitis  is 
infection.  The  particular  form  of  microbe  is,  as  yet,  sub  judice.  The  gono- 
coccus  is  considered  very  important  in  this  connection,  yet  it  is  highly 


ETIOLOGY    OF    CHBOXIC    CYSTITIS.  747 

probable  that  the  "'mixed"  quality  of  gonorrheal  infection  rather  than  the 
speciiic  microbe  is  the  chief  factor  in  gonorrheal  cystitis.  The  tubercle 
bacillus  excites  cystitis,  but  secondary  pus-infection  seems  to  be  more  im- 
portant than  the  tubercle  bacillus,  so  far  as  the  chronic  cystitis  per  se  is 
concerned.  Pyogenic  microbes  of  one  kind  or  another  are  the  essence  of 
vesical  infection,  no  matter  what  specific  nomenclature  may  be  applied  to 
the  germ  or  germs.  The  iaderium  coli  commune  has  been  frequently  found 
in  the  cystites,  and  has  been  shown  to  bear  a  most  important  relation  to  the 
inflammation.  Pyogenic  microbes  may  enter  the  bladder  via  the  circula- 
tion. Experiment  has  shown  that  the  colon  bacillus  may  traverse  the 
pelvis  from  the  intestine  and  infect  the  bladder. 

In  a  recent  interesting  article  by  Shrady  the  question  is  discussed  as 
to  how  the  bacillus  coli  finds  entry  to  the  bladder,  and  whether  it  always 
causes  cystitis.  It  has  been  found  in  the  urine  in  various  diseases  where 
there  is  apparently  no  cystitis.  Colicystitis  is  most  frequent  in  girls. 
Escherich  explains  this  upon  anatomic  grounds,  by  assuming  that  infection 
may  be  due  to  the  direct  contact  of  excremep.titious  products  with  the  geni- 
talia. 

It  has  been  held  that  there  may  be  direct  migration  of  bacilli  through  the 
intestinal  and  bladder-  walls  into  the  bladder.  This  is  admitted  by  Denys  only  when 
there  is  a  lesion  of  the  intestine;  but  Czerny,  Escherich,  and  Trumpp  have  found 
the  bacillus  coli  in  the  blood  in  enteritis.  Its  presence  has  also  been  demonstrated 
in  various  organs  of  the  cadaver.  A  general  coli-bacillus  poisoning  is  always  possible, 
for  the  virulence  of  this  particular  micro-organism,  under  favoring  conditions,  has 
not  been  exaggerated.^ 

Hutinel  reports  five  cases  of  colicystitis  in  girls,  between  two  and  ten 
years  of  age,  suffering  from  vulvo-vaginitis  and  recently  affected  by  a  more 
or  less  severe  enteritis. 

The  symptoms  were  discharge  of  mucus  from  the  vulva,  painful  diarrhea,  vesi- 
cal tenesmus;  scanty,  purulent  urine;  colon  bacilli  only,  and  transitory  fever  of 
remittent  type.  The  enteritis,  rather  than  the  vulvo-vaginitis,  was  the  principal 
cause  of  the  cystitis.^ 

The  most  frequent  source  of  vesical  infection  is  by  septic  instrumenta- 
tion. It  may  occur  spontaneously  via  the  urethra.  The  importance  of 
vesical  congestion  as  an  invitation  to  infection  is  again  to  be  remembered. 
Congestion  causes  excessive  secretion  of  mucus  and  a  loss  of  vitality  in  the 
vesical  mucosa:  conditions  that  are  ideal  for  the  culture  of  microbes.  The 
various  studies  that  have  been  made  of  bacterial  infection  of  the  bladder 
have  already  been  presented  in  extenso  in  a  preceding  chapter. 

Eovsing  classifies  the  different  forms  of  cystitis  as  follows: — 

1.  Catarrhal  or  non- suppurative  cystitis,  caused  by  non-pyogenic  organisms  that 
do  not  attack  the  mucosa  directly,  but  which  decompose  the  urine. 


1  Medical  Record,  March  20,  1897. 
^Presse  Medicale,  November  18,  1896. 


748  DISEASES    OF    THE    UEINAKT   BLADDER. 

2.  Suppurative  cystitis,  of  two  varieties,  viz.:  1.  Ammoniacal,  in  ^A'hicll  pyo- 
genic organisms  capable  of  decomposing  the  urine  are  present.  2.  Acid,  due  usually 
to  the  tubercle  bacillus. 

The  ammoniacal  variety  includes  cases  in  which  the  colon  bacillus  co-exists  with 
other  microbes  that  decompose  the  urine,  and  cases  in  which  the  latter  are  alone 
present.  Ammoniacal  cystitis  is  usually  due  to  septic  instrumentation  of  the  urethra. 
The  acid  suppurative  form  is  rarer  than  the  alkaline,  and  is  but  seldom  due  to  the 
passage  of  instruments.  The  microbes  concerned  in  cystitis  are  the  tubercle  bacillus, 
the  typhoid  bacillus,  the  gonococcus,  the  bacterium  coli,  and  the  streptococcus 
pyogenes.  They  enter  the  bladder  from  the  posterior  urethra,  or  come  down  by  the 
ureter  from  the  kidney.^ 

Eovsing  seems  to  overlook  the  probable  access  of  pathogenic  microbes 
to  the  bladder  via  the  blood. 

Melchior  also  holds  that  two  distinct  types  of  cystitis  are  met  with, 
the  urine  being  acid  in  the  one  and  alkaline  in  the  other. 

In  the  latter  some  of  the  germs  that  decompose  urea  and  liberate  ammonia  are 
found,  such  as  the  diplococcus  urese  liquefaciens,  bacillus  pyocyaneus,  etc.,  some- 
times with  and  sometimes  without  the  bacterium  coli.  In  the  acid  varieties  of  cys- 
titis, the  latter  organism  is  alone  gresent.- 

Morbid  Anatomy. — The  morbid  anatomy  of  chronic  inflammation  of 
the  bladder  is  well  worthy  of  carefnl  study,  as  it  is  common  to  all  genito- 
urinary diseases  of  a  chronic  obstructive  character,  vesical  or  urethral.  The 
vesical  walls  are  thickened  in  irregular  bands  or  trabeculas,  as  a  rule,  rarely 
uniformly  throughout.  The  mucosa  is  thickened,  rugose,  sacculated  to  a 
greater  or  less  degree,  and  of  a  slate  color.  Ulceration  is  rarely  present. 
The  surface  of  the  mucosa  is  usually  smeared  with  tenacious  muco-pus, 
and  perhaps  with  a  phosphatic  deposit.  Calculi  are  often  present,  as  might 
be  expected  from  a  consideration  of  the  causes  of  chronic  cystitis.  Ab- 
f erred  to  in  connection  with  the  subjects  of  vesical  calculus  and  urethral 
stricture. 

Disease  of  the  pelvis  of  the  kidney — perhaps  with  renal  calculi — may 
be  present.  In  a  large  proportion  of  cases  stricture  or  chronic  urethral  in- 
flammation exists.  -  These  various  pathologic  phenomena  will  again  be  re- 
ferred to  in  connection  with  vesical  calculus  and  urethral  stricture. 

Chronic  cystitis  without  catarrh  has  been  described.  The  author  does 
not  accept  its  existence,  as  will  be  shown  in  connection  with  the  subject  of 
vesical  hyperesthesia.  Cases  are  reported,  however,  where,  as  proved  by 
autopsy,  cystitis  existed  without  subjective  symptoms.^ 

Symptoms. — The  symptoms  of  chronic  cystitis  are  a  modification  of 
those  of  the  acute  form.  They  are  chiefly  referable  to  the  act  of  micturi- 
tion. Urination  is  frequent  and  scanty,  the  bladder  being  intolerant  of 
even  a  small  quantity  of  urine.    More  or  less  vesical  tenesmus — with  pain 


^  Annales  des  Mai.  d.  Org.  Genito-Urin.,  Oct.  to  Dec,  1897. 

^  Centralblatt  fiir  die  Krankheit  der  Ham.  u.  Sexualorgane,  May,  1897. 

^WoUstein,  Medical  Eecord,  January  23,  1897. 


TREATMENT    OF    CHEONIC    CYSTITIS.  749 

before,  during,  and  following  micturition — is  a  constant  symptom.  The 
urine  is  fetid  and  ammoniacal,  and  loaded  with  muco-pus  and  phosphates 
in  advanced  cases;  but  in  some  cases  of  shorter  duration  it  is  acid  when 
voided,  becoming,  however,  speedily  decomposed.  Often  the  urine  contains 
more  or  less  blood,  this  being  a  very  frequent  symptom  in  cystitis  sec- 
ondary to  vesical  calculus. 

The  constitutional  symptoms,  although  not  characteristic,  are  usually 
a  prominent  feature  of  the  case.  There  are  few  diseases  that  produce  a 
like  amount  of  worriment  and  nervous  irritability.  Considerable  debility 
and  nervous  prostration  from  pain  and  sleeplessness  are  apt  to  be  present, 
especially  in  elderly  patients.  There  is  likely  to  be  more  or  less  fever.  A 
very  important  consideration  in  the  study  of  the  constitutional  symptoms 
is  the  condition  of  the  kidneys.  These  organs  are  usually  affected,  pri- 
marily or  secondarily,  and,  as  a  consequence,  their  functions  are  very  im- 
perfectly performed,  and  the  patient  necessarily  suffers  from  more  or  less 
marked  uremia,  or  at  least  from  imperfect  renal  elimination  in  general, 
incident  to  renal  inadequacy.  Absorption  of  the  products  of  urinary  de- 
composition must  necessarily  constitute  a  prominent  factor  in  chronic  ob- 
structive lesions  of  the  urinary  tract,  although  it  is  difficult  to  determine 
precisely  what  toxic  principles  are  responsible  for  the  injury  produced  by 
such  absorption.  The  experiments  of  Selmi  and  Gantier  in  the  study  of 
ptomains  and  leucomains  give  a  hint  as  to  the  true  condition  of  affairs,  and 
afford  a  plausible  explanation  of  much  of  the  ill  health  of  subjects  with 
chronic  cystic  disease.  Eeginald  Harrison  has  recently  expressed  his  belief 
in  similar  toxic  principles  as  a  cause  for  "urine-fever."^  The  author  has 
already  discussed  chronic  general  infection  in  cystitics  under  the  heading 
of  chronic  urinary  intoxication  in  the  chapter  embracing  urinary  fever. 

One  of  the  most  frequent  phenomena  to  be  referred  to  defective  renal 
activity  is  an  unhealthy  state  of  the  skin.  Eczema  is  quite  often  seen,  and 
is  the  direct  result  of  vicarious  action  upon  the  part  of  the  skin. 

Diagnosis. — The  diagnosis  of  chronic  cystitis  is  a  very  simple  matter, 
but  to  determine  the  primary  condition  upon  which  it  depends  is  by  no 
means  easy  in  all  cases.  Having  determined  the  existence  of  cystitis,  how- 
ever, a  careful  exploration  of  the  urethra,  prostate,  bladder,  and  kidneys  will 
usually  reveal  the  cause  of  the  disease.  A  careful  examination  of  surround- 
ing structures,  and  especially  of  the  rectum,  is  quite  essential,  and  in  some 
cases  will  clear  up  an  otherwise  doubtful  diagnosis.  A  careful  examination 
of  the  urine  is  always  necessary,  both  for  diagnosis  and  to  determine  the  con- 
dition of  the  kidneys. 

Treatment. — The  treatment  of  chronic  cystitis  consists,  in  the  larger 
proportion  of  cases,  of  the  treatment  of  its  cause.  The  removal  of  stricture, 
stone,  vesical  tumors,  or  the  cure  of  a  primar}^  or  secondary  pyelitis  are 


^Lettsomian  Lectures,  1888. 


750  DISEASES    OF    THE    UEIA^AKY   BLADDEK. 

among  the  prominent  indications  that  exist  in  different  cases^  and^  by  meet- 
ing them,  a  radical  cure  is  often  effected. 

In  a  certain  proportion  of  cases  the  condition  is  primarily  an  infective 
one,  and  treatment  should  be  mainly  directed  to  antagonizing  infection  by 
both  local  and  oral  medication. 

The  diet  requires  careful  regulation,  an  excess  of  nitrogenized  food 
being  especially  harmful.  Milk  should  be  the  staple  article  of  diet.  Liquor 
and  tobacco  should  be  interdicted,  as  a  rule.  Vegetables — with  the  excep- 
tion of  asparagus,  tomatoes,  and  rhubarb — are  permissible.  Frequent  hot 
sitz-baths  are  of  great  service,  and  are  too  little  used  in  such  cases.  The 
Turkish  bath  is  also  valuable. 

Guy  on  has  analyzed  a  series  of  116  cases  and  has  verified  the  impor- 
tance of  general  therapeutic  measures  in  all  forms  of  cystitis.  He  claims 
that  the  internal  administration  of  creasote  is  the  most  reliable  method  of 
general  treatment.  He  emphasizes  the  necessity  of  very  gentle  local  meas- 
ures, especially  at  first,  on  account  of  the  extreme  sensitiveness  of  the  blad- 
der. He  condemns  boric  acid,  and  uses  instillations  of  mercuric-chlorid 
solution  and  guaiacol. 

The  drugs  that  may  be  required  in  different  cases  of  cystitis  are  com- 
paratively few,  and  do  not  comprise  any  remedies  that  can  Justly  be  re- 
garded as  specifics.  The  various  preparations  of  opium,  belladonna,  and 
hyoscyamus  are  the  best  remedies  to  allay  pain  and  vesical  irritability  and 
to  promote  rest.  They  should  be  given  by  suppository.  Alkalies  are  often 
of  service,  especially  when  combined  with  the  vegetable  acids.  They  are 
not  serviceable,  however,  in  advanced  cases,  in  which  the  urine  is  strongly 
ammoniacal,  save  through  their  action  in  stimulating  the  renal  function 
and  diluting  the  urine.  In  the  earlier  stages,  and  in  cases  in  which  there 
is  little  or  no  residual  urine,  they  are  exceedingly  beneficial.  This  is  ex- 
plained by  the  fact  that  the  urine  in  such  cases  comes  down  from  the  kid- 
neys in  a  highly  concentrated  and  acid  condition  that  renders  it  very  irri- 
tating to  the  vesical  mucosa.  The  induced  irritation  excites  a  secretion  of 
mucus  that  tends  to  excite  decomposition  in  the  urine.  Correction  of  the 
primary  acidity  of  the  urine  will  therefore  lessen  the  irritation  and  hyper- 
secretion of  mucus.  Certain  remedies  seem  to  exert  a  particularly  bene- 
ficial effect  upon  the  inflamed  membrane,  the  balsams  being  especially 
reliable.  Sandal-wood,  copaiba,  cubebs,  and,  in  some  cases,  turpentine  are 
of  great  value.  Benzoic  acid  and  benzoate  of  soda  are  sometimes  useful. 
Infusions  of  buchu,  triticum  repens,  pareira  brava,  uva  ursi,  chimaphila, 
kava-kava,  slippery  elm,  linseed,  and  barley  are  all  more  or  less  beneficial. 
Sir  Henry  Thompson  especially  favors  pareira  brava. 

Where  the  stomach  will  tolerate  it,  a  combination  of  the  oil  of  euca- 
lyptus and  salol  in  capsule  is  one  of  the  most  valuable  remedies  at  our  com- 
mand. It  is  certainly  the  most  reliable  of  all  urinary  antiseptics.  Guaiacol, 
boric  acid,  and  meth3'l-violet  are  also  valuable,  guaiacol  being  especially  so. 


TREATMENT    OF    CHEONIC    CYSTITIS.  751 

Balsam  of  Peru  and  the  tincture  of  rlius  aromatica  are  often  of  service. 
Among  the  newer  remedies  of  greater  or  less  value  are  pichi  and  saw  pal- 
metto. Much  has  been  written  in  eulogy  of  the  latter,  three-fourths  of 
which,  in  the  author's  opinion,  is  rubbish,  written  by  men  with  a  feverish 
anxiety  to  get  into  print.  In  most  cases  the  balsams  or  guaiacol  will  give 
better  results. 

Urotropin — cystogen — has  been  highly  recommended  for  internal  ad- 
ministration in  cystitis.  Its  non-toxic  and  non-irritating  character  and  ex- 
treme solubility  in  water  are  properties  that  especially  commend  it.  It  has 
a  marked  diuretic  influence,  and,  it  is  claimed,  is  antilithic  in  high  degree, 
although  it  increases  the  ordinary  acid  reaction  of  the  urine.  It  is  to  be 
given  in  doses  of  from  5  to  15  grains  four  times  daily,  largely  diluted.  It 
has  been  claimed  that  the  ammoniacal  odor  of  the  urine  in  advanced  cases 
soon  disappears  under  the  use  of  urotropin,  the  urine  clearing  up  and  be- 
coming acid  and  its  sediments  disappearing.  The  antiseptic  action  of 
cystogen  has  been  said  to  be  due  to  its  conversion  into  formalin.  In  the 
author's  experience  cystogen  is  inferior  to  eucalyptus. 

Some  of  the  alkaline  or  neutral  mineral  waters  act  well  as  diuretic 
and  diluent  drinks,  the  natural  Vichy,  Seltzer,  Apollinaris,  Waukesha, 
Geneva  or  Londonderry  lithia,  and  Bethesda  waters  being  all  more  or  less 
beneficial.  The  Garrocl  Spa,  already  mentioned,  is  the  best  of  the  artificial 
waters,  and  far  superior  to  most  natural  waters  where  an  alkaline  diuretic 
water  is  required.  Simple  hot  distilled  water  taken  while  fasting  will  be 
found  to  exert  a  surprisingly  beneficial  effect  by  rendering  the  urine  bland 
and  unirritating  and  flushing  out  the  bladder.  Boric  acid  adds  to  its  effi- 
ciency. Simple  as  it  may  seem,  distilled  water  is  oftentimes  a  better  remedy 
than  any  of  the  expensive  and  fanciful  mineral  waters.  It  acts  better  when 
taken  hot.  It  can  be  made  alkaline  by  the  addition  of  sodium  bicarbonate 
in  rather  free  doses. 

Tonics  are  required  in  the  majority  of  cases,  the  various  bitters,  such 
as  cinchona,  and  the  various  preparations  of  iron,  quinin,  and  strychnin, 
being  the  most  useful  of  this  class  of  remedies.  Should  a  stimulant  seem 
to  be  indicated,  the  preparations  of  coca  will  be  found  to  be  very  beneficial. 

The  local  treatment  of  cystitis  is  the  most  important  consideration,  and 
requires  some  nicety  of  judgment.  After  the  primary  organic  disease  has 
been  discovered  and  removed,  or  its  removal  has  been  shown  to  be  imprac- 
ticable, the  less  instrumentation,  in  a  general  way,  the  better  for  the  pa- 
tient. Most  cases,  however,  are  benefited  greatly  by  irrigation  of  the  blad- 
der. Warm  solutions  of  antiseptics  are  best  for  this  purpose.  Among  the 
most  popular  drugs  are  weak  solutions  of  carbolic  acid,  creolin,  salicylic 
acid,  nitric  acid,  nitrate  of  silver,  naphthol,  boric  acid,  and  potassium  per- 
manganate. Glycerin,  linseed-oil,  and  iodoform  are  also  recommended. 
Linseed-oil  will  be  found  to  be  very  effective  in  many  cases.  The  author's 
preference  for  the  purpose  of  irrigation  is  the  following  formula: — 


752  DISEASES    OF    THE    UEINARY    BLADDER. 

IJ  Ac.  carbolic! §ij. 

Sodii  biboratis §iv. 

Sodii  salieylatis • §ij. 

Glycerin!   Oj. 

M.  Sig. :  Use  gss  to  each  pint  of  warm  water,  and  add  as  much  boric  acid  as 
can  be  dissolved  in  the  lotion. 

When  there  is  much  pain  a  small  quantity  of  a  solution  of  cocain  may 
be  thrown  into  the  bladder  and  allowed  to  remain  after  the  irrigation  is 
completed. 

A  soft  catheter  of  the  ordinary  form  will  be  found  to  be  quite  as  serv- 
iceable as  some  of  the  more  elaborate  contrivances  for  washing  the  bladder. 
The  fluid  should  be  introduced  by  means  of  the  fountain-syringe. 

Where  practicable,  the  patient  should  be  irrigated  without  either  cathe- 
ter or  tube, — by  hydrostatic  pressure.  The  short  urethral  nozzle  designed 
by  the  author  is  very  useful  for  this  purpose. 

Some  cases  are  made  worse  by  irrigation,  hence  it  is  to  be  used  with 
a  certain  amount  of  caution.  The  fluid  should  be  introduced  in  small  quan- 
tities at  a  time,  and,  if  the  cystitis  seems  to  be  aggravated,  the  treatment 
should  be  stopped.  It  is  a  good  plan  to  leave  a  small  amount  of  the  anti- 
septic solution  in  the  bladder,  and  instruct  the  patient  to  retain  it  as  long 
as  possible. 

If  the  cystitis  be  of  gonorrheal  origin,  the  range  of  local  remedies  is 
practically  limited  to  potassium  permanganate,  mercury  bichlorid,  and 
silver  nitrate,  in  solutions  of  varying  strength. 

In  all  forms  of  chronic  cystitis,  but  especially  in  the  tubercular  variety, 
the  author  has  obtained  excellent  results  from  the  following: — 

IJ  Iodoform!    Sj. 

Mther.  sulph §j. 

Albolene q.  s.  ad  Sviij. 

M.  Sig.:  Inject  from  1  to  3  ounces  into  the  bladder  once  daily.  Should  the 
bladder  resent  this,  cocain  should  be  injected  first.  As  a  preliminary  measure,  it  is 
well  to  irrigate  the  bladder  with  warm  boric  solution. 

When  all  ordinary  plans  of  treatment  have  proved  ineffectual,  the  onlj 
hope  of  relief  is  in  cystotomy.  The  combined  method  of  suprapubic  and  peri- 
neal cystotomy  gives  the  best  results,  though  either  alone  may  be  successful. 
If  only  one  opening  is  made,  the  suprapubic  method  offers  the  best  prospect 
of  cure. 

Cystotomy  is  often  successful  in  chronic  cystitis,  and,  in  the  author's 
opinion,  is  not  performed  sufficiently  often.  It  should  be  performed  before 
the  patient  is  completely  exhausted  and  while  the  kidneys  are  in  fair  con- 
dition, or  there  will  be  very  little  chance  of  recovery.  Curettement  may  be 
practiced  in  some  cases.  After  the  operation  free  dietetic  and  tonic  support, 
with  perfect  drainage  and  antiseptic  irrigations,  are  indicated. 


ULCEE    OF    THE    BLADDER.  753 

Slioiild  the  typhoid  condition  supervene,  it  requires  the  same  measures 
as  in  acute  cystitis — which,  indeed,  is  lilvely  to  develop  at  any  time. 

Cystitis  in  the  Female. — Cystitis  in  the  female  is  due  to  the  same 
general  causes  and  presents  the  same  morbid  changes  as  in  the  male,  and, 
in  addition,  it  may  depend  upon  such  special  causes  as  reflex  irritation  from 
uterine  disease  or  pressure  upon  the  bladder  by  a  gravid  or  a  misplaced 
uterus,  fibroid  tumor,  or  ovarian  cyst.  Obstruction  by  urethral  caruncle 
has  been  known  to  cause  it.  It  has  been  observed  also  in  some  cases  of 
hysteric  retention.  Struma  in  young  girls  is  sometimes  productive  of  a 
chronic  congestion  and  thickening  of  the  vesical  mucosa  that  eventuates  in 
chronic  cystitis.  Pelvic  cellulitis — i.e.,  pelvic  peritonitis  and  salpingitis — 
is  apt  to  be  associated  with  cystitis,  as  a  consequence  of  the  pressure  of  the 
inflammatory  exudate,  or,  later  on,  from  rupture  of  resulting  pelvic  abscess 
into  the  bladder.  Transperitoneal  infection  from  rectum  and  uterus  have 
been  known  to  occur. 

Treatment.— -The  treatment  of  cystitis  in  the  female  is  essentially  the 
same  as  in  the  male,  excepting  that,  inasmuch  as  the  urethra  is  short  and 
readily  accessible,  it  may  be  dilated  with  advantage,  almost  as  a  matter  of 
routine.  On  account  of  its  peculiar  anatomic  arrangement,  incision  of  the 
bladder  is  rarely  necessary,  dilation  being  sufficiently  radical  for  the  ma- 
jority of  cases.  In  cases  of  uterine  displacement  pessaries  are  necessary. 
If,  however,  the  organ  is  bound  down  by  old  adhesions,  vaginal  or  supra- 
pubic cystotomy  is  required.  So  great  is  the  relief  afforded  by  this  simple 
operation  that  a  single  experience  with  it  in  a  long-standing  case  of  cys- 
titis is  sufficient  to  demonstrate  its  efficacy  and  safety. 

In  a  number  of  cases  of  chronic  cystitis  in  women  the  author  has  ob- 
tained exceedingly  gratifying  results  from  dilation  of  the  urethra,  fol- 
lowed by  applications  of  strong  solution  of  silver  nitrate  to  the  entire  ves- 
ical mucosa  via  the  endoscope.  A  strength  of  3ij  to  the  ounce  appears  safe. 
In  some  cases  the  thickened  and  infiltrated  vesical  mucosa  is  greatly  im- 
proved by  gentle  curettement  with  a  moderately  blunt  curette.  This  pro- 
ceeding has  been  of  service  in  the  author's  experience  on  several  occasions. 

VESICAL    ULCEE. 

Ulceration  of  the  bladder  is  generally  the  result  of  tubercular  or  malig- 
nant infiltration;  rarely,  indeed,  is  it  of  a  simple  character  and  due  to 
acute  or  chronic  inflammation.  It  may  result  from  strong  irritants  thrown 
into  the  bladder  by  injection.  When  not  due  to  some  special  disease  of  the 
mucous  membrane  it  is  generally  of  traumatic  origin.  Thus  it  may  com- 
plicate cystitis  secondary  to  stone,  as  a  consequence  of  constant  friction, 
pressure,  and  bruising  during  the  movement  of  the  foreign  body.  It  may 
also  result  from  the  pressure  of  instruments  that  have  been  allowed  to  re- 
main in  the  bladder. 

Diagnosis. — The  diagnosis  of  ulceration  of  the  bladder  is  frequently 


754  DISEASES    OF   THE    UKINARY   BLADDEE. 

made  in  a  most  careless  manner.  Diagnosis  is  not  possible  without  the  aid 
of  the  cystoscope.  Very  frequently  this  instrument  cannot  be  used  because 
of  vesical  intolerance  for  the  amount  of  fluid  necessary  for  exploration.  In 
advanced  carcinoma  or  tubercle  of  the  bladder  ulceration  may  be  inferred 
to  be  present.  . 

Treatment. — The  treatment  is  that  of  chronic  inflammation.  Caution 
is  necessary,  however,  in  regard  to  the  administration  of  narcotics  by  ves- 
ical injection.  The  bladder  while  intact  absorbs  drugs  very  sparingly,  but 
when  its  mucous  membrane  has  been  eroded  and  its  epithelium  removed 
absorption  occurs  at  the  denuded  spot  quite  as  readily  as  in  other  mucous 
membranes.  Serious  and  even  fatal  results  have  been  recorded  from  the 
careless  use  of  opium  and  powerful  antiseptics  under  such  circumstances. 

GANGRENE  OF  THE  BLADDEE. 

Vesical  gangrene  is  an  occasional  result  of  acute  inflammation.  It  con- 
sists of  sloughing  of  the  mucous  and  submucous  tissues,  and  not  of  the 
muscular  walls,  as  a  rule,  although  some  of  the  inner  muscular  fibers  may 
be  involved  in  occasional  instances.  It  is  most  apt  to  occur  in  broken- 
down  and  aged  patients,  as  a  consequence  of  acute  infectious  inflamma- 
tion following  overdistension  by  retained  urine.  Thus,  too  sudden  and 
complete  evacuation  of  the  bladder  in  cases  of  prolonged  retention  in  long- 
standing cases  of  obstructive  lesions  of  the  urethra,  bladder,  or  prostate  is 
apt  to  be  followed  by  acute  inflammation  and  sloughing  of  the  mucous 
membrane.  When  the  inflammation  and  sloughing  do  not  prove  fatal — 
which  is  exceptional— the  condition  is  apt  to  result  in  more  or  less  ex- 
tensive ulceration  of  the  mucous  surface.  It  was  long  supposed  that  ves- 
ical gangrene  following  prolonged  retention  was  due  entirely  to  circulatory 
changes:  i.e.,  acute  hyperemia  of  tissues,  the  vitality  of  which  had  been 
weakened  by  pressure.  This,  however,  is  an  error.  The  nutritional  and  cir- 
culatory disturbance  simply  afford  a  favorable  soil  for  germ-infection. .  The 
bladder-contents  being  infected,  acute  local  sepsis  and  necrotic  inflamma- 
tion occur  immediately  pressure  is  removed  by  sudden  evacuation  of  the 
bladder.  Profound  asthenia,  the  typhoid  condition,  and  speedy  death  are 
the  usual  characteristics  of  vesical  gangrene. 

Diagnosis. — The  diagnosis  of  vesical  gangrene  is  readily  made,  as  the 
shreds  of  necrosed  mucous  membrane  appear  in  the  urine.  Quite  often  a 
characteristic  gangrenous  odor  is  perceptible.  The  constitutional  symp- 
toms afford  conflrmatory  evidence. 

Treatment. — The  treatment  of  vesical  gangrene  should  consist  of  free 
stimulation  and  a  generous  diet,  in  addition  to  special  measures  for  the 
relief  of  the  inflammation  upon  which  the  gangrene  depends.  Unfortu- 
nately, however,  a  fatal  result  is  usual,  the  patient,  in  spite  of  all  treat- 
ment, dying  of  exhau.stion. 


HYPEETEOPHY  AXD  ATEOPHY  OF  THE  BLADDEE.  755 

Vesical  gangrene  can  usually  be  prevented  by  leaving  sufficient  warm, 
mild  antiseptic  lotion  in  the  bladder  after  evacixating  the  urine  in  retention. 
Careful  and  copious  antiseptic  irrigation  lessens  the  danger  of  infection. 
Boric-acid  solution  or  mercuric-chlorid  solution — 1  to  30^000 — may  be  used. 

VESICAL    ABSCESS. 

Abscess  in  and  about  the  bladder-walls  is  a  very  rare  condition,  and 
probably  never  occurs  as  a  primary  disease.  It  may  be  secondary  to  ulcera- 
tion, calculus,  prostatic  or  urethral  obstructive  disease,  tubercular  or  can- 
cerous infiltration,  tubo-ovarian  disease  with  secondary  pelvic  abscess  in- 
volving the  bladder  and  perhaps  opening  into  it,  or,  in  rare  cases,  to  rupture 
of  a  simple  abscess  in  the  cellular  tissue  about  the  bladder.  Traumatism 
with  secondary  infection  may  possibly  cause  abscess  of  the  vesical  walls, 
this  being  the  nearest  approach  to  primary  vesical  abscess  ever  met  with. 

HYPEETEOPHY  AND  ATEOPHY  OF  THE  BLADDEE. 

These  conditions  of  the  vesical  walls  are  prominent  factors  for  consid- 
eration in  the  study  of  various  irritative  and  obstructive  diseases  of  the 
genito-urinary  tract.  The  two  conditions  are  generally  associated,  and  are 
never  met  with  as  primary  affections.  Where  there  is  considerable  hyper- 
trophy of  the  muscular  fasciculi  of  the  detrusor  urinse,  the  areas  of  blad- 
der-wall between  the  muscular  bundles  are  thinned  and  atrophic.  This  is 
the  condition  that  is  apt  to  lead  to  the  formation  of  vesical  sacculi.  In 
some  few  cases  there  seems  to  be  a  general  deficiency  of  the  muscular  coats 
of  the  bladder,  on  the  one  hand,  or  an  evenly-disseminated  hypertrophy, 
upon  the  other.  Thus,  the  bladder  may  be  so  greatly  thinned  that  there 
is  great  danger  of  rupture,  or  it  may  be  so  thickened,  as  a  result  of  com- 
pensatory hypertrophy  and  sclerosis  in  old  cases  of  vesical  inflammation,  that 
the  walls  are  over  an  inch  in  thickness,  and  the  cavity  so  contracted  as  to  be 
incapable  of  holding  even  a  few  drams  of  urine.  These  changes  in  the  mus- 
cular and  fibrous  structures  of  the  bladder  are  precisely  similar  to  those  oc- 
curring in  the  walls  of  any  hollow  viscus  under  the  conditions  of  obstruction 
and  inflammation.  As  an  illustration  of  the  effects  of  obstruction  to  the  out- 
flow from  hollow  viscera,  the  dilation  and  thinning,  on  the  one  hand,  and 
hypertrophy,  on  the  other,  of  the  cardiac  muscle  consequent  upon  obstruc- 
tive valvular  lesions  are  worthy  of  attention. 

Treatment. — The  treatment  of  atrophy  and  hypertrophy  of  the  blad- 
der is  that  of  the  special  conditions  to  which  they  are  secondary;  indeed, 
we  have  no  means  of  diagnosing  their  existence  excepting  inferentially. 
Localized  hypertrophy  of  the  mucous  and  muscular  tissues  of  the  bladder 
is,  however,  sometimes  a  matter  of  some  importance;  thus,  when  the  uvula 
vesiccB  and  the  sublying  tissues  are  involved,  we  have  developed  the  so-called 
''bar  at  the  vesical  neck."     This  is  a  serious  obstacle  to  instrumentation. 


756  DISEASES  or  the  ukikaey  bladder. 

and  affords  an  excellent  opportunity  for  the  collection  of  nrine  behind  it. 
This  residual  nrine,  as  may  be  observed  in  almost  every  phase  of  obstrnctive 
disease  of  the  urinary  passages,  is  productive  of  marked  discomfort,  as  well 
as  organic  changes  in  the  tissues  involved.  The  bar  is,  moreover,  always 
secondary  to  chronic  disease  of  the  urethra,  prostate,  or  bladder,  and  as  such 
must  be  taken  into  consideration  in  their  study  and  treatment.  There  are 
no  special  surgical  measures  for  the  relief  of  this  bar,  save  cystotomy,  peri- 
neal or  suprapubic.  After  opening  the  bladder  the  obstruction  may  be 
amenable  to  the  galvanocautery,  which  instrument,  by  the  way^,  has  prob- 
ably a  brilliant  future  in  the  management  of  chronic  bladder  and  prostatic 
disease. 


CHAPTER  XXXIII. 

Neoplasms  of  the  Bladder: 

papilloma,  myxoma,  fjbroma,  myoma,  saecoma,  carcinoma; 

AND  Vesical  Tuberculosis. 

Tumors  or  new  growths  of  the  urinary  bladder  are  of  special  impor- 
tance on  account  of  their  location  rather  than  the  possession  of  any  peculiar 
qualities. 

Almost  every  known  variety  of  tumor  has  been  met  with  in  or  about 
the  bladder.  Thus  we  meet  with  fibroid  tumors,  soft  sessile  and  polypoid 
adenomata,  cysts,  sarcoma,  encej^haloid,  scirrhus,  epithelioma,  and  villous 
or  vascular  tumor. 

BENIGN    vesical    GROWTHS. 

Vesical  Papilloma. — Villous  tumor,  or  papilloma,  is  by  far  the  most 
frequent,  and  consequently  the  most  important,  of  the  vesical  new  growths. 


Fig.  153. — Simple  papilloma  of  the  bladder.     (After  Thompson.) 

It  is  the  only  one  of  the  neoj^lasms  to  which  the  bladder  is  subject  that  may 
be  said  to  be  curable  in  any  degree,  and  even  it  may  be  said  to  often  oc- 
cupy the  phantom-like  line  dividing  malignant  from  non-malignant  growths 
occurring  in  this  locality.  In  the  majority  of  cases  villous  tumor  is  of 
the  nature  of  benign  papilloma  .or  fibropapilloma,  and  is  probably  of  this 
character  primarily  in  every  ease,  becoming  malignant  secondarily,  if  at  all. 
The  term  "villous  caneer,^^  so  often  applied  to  it,  is  therefore  inaccurate. 
When  malignant  change  does  occur,  it  is  by  transformation  into  epi- 
thelioma, 

(757) 


758 


]s*eoplas:ms  of  the  bladdee. 


In  its  gross  appearance  vesical  papilloma  presents  a  more  or  less  con- 
sistent base,  firmly  attached  to  the  vesical  mucosa,  from  which  numerous 
delicate,  highly  vascular,  branching  processes  float  freely  out  into  the  cav- 
ity of  the  bladder  when  distended  by  urine.  These  branching  processes 
or  filaments  consist  of  fragile  capillary  loops  covered  by  fine  pavement-epi- 
thelium and  bound  together  by  delicate  connective  tissue.  As  with  all  ves- 
ical tumors,  the  physical  characters  of  papillomata  may  become  obscured 
by  the  deposition  and  incrustation  of  triple  phosphates  and  mucus  upon  its 
surface. 

The  location  of  the  villous  tumor  is  usually  the  trigonum  vesicae,  al- 
though it  may  occur  in  any  situation  upon  the  vesical  mucosa.  It  is  less 
likely  to  prove  malignant  when  situated  at  the  trigone.  The  tumor  is 
multiple  in  nearly  one-half  the  cases. 


Fig.  154. — Vesical  fibropapilloma..     (After  MouUin.) 


Villous  tumors  vary  in  form.  In  some  cases  the  growth  has  a  broad, 
sessile  base,  and  presents  a  conformation  quite  like  that  of  a  cauliflower. 
In  other  instances  it  is  pedunculated  and  floats  freely  in  the  urine.  The 
pedicle  may  be  very  thin.  In  rare  instances  the  entire  vesical  mucosa  is 
thickly  studded  with  fine  papillomatous  growths.  When  malignant  trans- 
formation occurs,  the  transition  is  into  epithelioma;  recurrence  after  re- 
moval is  usually  in  the  form  of  epithelioma.  Unfortunately,  recurrence  is 
usual,  the  now  malignant  growth  developing  quickly  and  degenerating 
rapidly. 

Symptoms. — The  symptoms  of  vesical  papilloma  are  in  general  those 
common  to  vesical  growths.  Secondary  cystitis  comes  on  sooner  or  later, 
in  which  event  disturbance  of  micturition  develops,  and  is  modified  by  the 
size  and  location  of  the  growth.     Where  the  growth  is  large,  or  located  in 


PAPILLOMA    OF   THE    BLADDER. 


759 


such,  a  position  as  permits  it  to  obstruct  the  vesical  neck,  frequent  and  dif- 
ficult micturition  develops  early. 

Hemorrhage — i.e.,  hematuria — is  usually  the  first  symptom  that  occurs. 
This  is  variable  in  amount;  finally  becomes  profuse,  as  a  rule;  and  is  a 
prime  factor  in  destroying  life.  The  hematuria  is  due  to  rupture  of  the 
delicate  vascular  loops  of  the  growth,  and  is  consequently  increased  by 
mechanic  disturbance,  such  as  jolting  of  the  body  or  exploration  of  the 


Fig.  155. — Histology  of  filaments  of  papilloma  of  the  bladder. 
(After  Thompson.) 

bladder.  Anemia,  debility,  and  cachexia  are  prominent,  according  to  the 
amount  of  hemorrhage  and  degree  of  degeneration  of  the  neoplasm.  Ca- 
chexia is  proportionate  to  the  degree  of  malignancy  presented  by  the  growth. 
Diagnosis. — The  symptoms  of  the  various  forms  of  vesical  tumors  are 
so  much  alike  that,  even  granting  that  the  diagnosis  of  tumor  has  been 
established,  it  is  often  difficult  to  determine  which  variety  is  present.  Ves- 
ical hemorrhage  coming  on  suddenly  without  known  cause,  and  without 
preliminary  bladder  symptoms,  is  always  suspicious  of  tumor.     A  recur- 


760  XEOPLASMS    OF    THE    BLADDEE. 

rence  of  liemorrliage  from  time  to  time  warrants  a  probable  diagnosis  of 
tnmor,  especiall}'  if  there  is  no  other  local  explanation  of  the  hematuria. 
Cystitis  may  be  deferred  for  a  long  time  in  vesical  tumor,  especially  if  the 
bladder  is  not  infected  from  without.  Fragments  of  the  growth  may  be- 
come detached  and  appear  in  the  voided  urine,  thus  establishing  the  diag- 
nosis. Bladder-epithelium  is  abundant.  The  cystoscope  will  quite  likely 
clear  up  the  diagnosis  if  used  between  hemorrhages.  With  the  irrigating 
cystoscope,  accurate  exploration  is  sometimes  practicable,  even  during 
hemorrhage.  It  is  sometimes  possible  to  examine  the  bladder  with  the 
ordinary  cystoscope,  while  the  viscus  is  distended  with  an  astringent  solu- 
tion, even  though  hematuria  exists.  Often,  however,  there  is  no  diagnostic 
recourse  other  than  cystotomy.  White  advises  deferring  all  exploration 
until  preparations  have  been  made  for  immediate  cystotomy  and  resection 
of  the  tumor  in  case  one  be  found.  This  is  for  the  purpose  of  avoiding  the 
infection  and  resulting  cystitis  to  which  such  cases  are  peculiarly  suscepti- 
ble when  the  bladder  is  explored.  Wlien  the  characteristic  fragments  of 
papilloma  are  found  in  the  urine,  the  diagnosis  is  easy,  and  if  the  case  is 
seen  at  an  early  period  its  non-malignancy  may  be  inferred.  The  great 
danger  of  epitheliomatous  or  even  sarcomatous  transformation  should  be 
borne  in  mind,  however.  It  should  also  be  remembered  that  papilloma  is 
likely  to  produce  death  by  repeated  hemorrhages,  secondary  cystitis,  and 
surgical  kidney;  hence  the  treatment  should  be  in  nowise  modified  by  the 
inferential  benignit}^  of  the  growth. 

Prognosis. — "When  nninterfered  with,  papilloma  of  the  bladder  usually 
proves  fatal.  The  causes  of  death  are:  1.  Chronic  anemia  from  hemorrhage. 
2.  Exhaustion  and  toxemia  from  malignant  degeneration.  3.  Purulent  in- 
fection and  uremia  from  cystitis  and  pyelonephritis — "'surgical  kidney." 
Backward  pressure  upon  the  kidneys  from  mechanic  obstruction  of  the 
ureters  is  an  important  element  in  the  secondary  renal  disease.  4.  Acute 
anemia  from  hemorrhage  (this  occurs  occasionally  only). 

The  duration  of  papilloma  is  an  uncertain  quantity.  It  depends  largely 
upon  the  frequeiicy  and  severity  of  the  hematuria  and  is  governed  to  a 
certain  extent  by  the  degree  of  intrinsic  tendency  to  malignant  degenera- 
tion it  presents.    A  case  is  recorded  of  eleven  years'  duration.^ 

Treatment. — The  treatment  of  vesical  papiUoma  is  that  of  vesical  tu- 
mors in  general,  and  will  be  presented  later. 

])klTXOMA. — In  order  of  frequency,  myxoma  of  the  bladder  is  next  to 
papilloma  among  the  benign  vesical  tumors.  It  is,  however,  much  less  fre- 
quent than  papilloma.  It  is  most  often  found  in  children,  and  cases  of 
apparently  congenital  origin  have  been  reported.  Pure  myxoma  is  rarely, 
if  ever,  found,  a  certain  proportion  of  fibrous  tissue  entering  into  the  com- 
position of  the  growth.     The  pathologic  nomenclature  depends  upon  the 


^Hudson,  Dublin  .Journal  of  Medical  Science.  1879. 


riBKOMA   AND    MYOMA    OP    THE    BLADDER. 


'61 


relative  amount  of  fibroid  and  myxomatous  tissue.  Thus,  if  the  former 
prejDonderates,  the  growth  is  termed  fibromyxoma;  if  the  latter,  myxo- 
fibroma. In  rare  cases  sarcoma  and  myxoma  are  conjoined.  Vesical  myxo- 
mata  strongly  resemble  nasal  polypi,  are  often  multiple,  and  quite  likely 
to  be  pedunculated.  Obviously,  the  consistency  of  the  growths  varies  ac- 
cording to  the  relative  proportion  of  fibroid  and  mucous  tissue  in  their 
composition. 

Fibroma  and  Myoma. — Tumors  composed  mainly  of  fibroid,  or  mus- 


/ 


Fig.  156. — Myxosarcoma.     (After  Albarran.) 


cular  tissue,  are  very  rarely  found  in  the  bladder.  Pure  fibromata  are  met 
with  still  more  rarely.  They  spring  from  the  submucous  coat  of  the  organ. 
Myoma  has  its  origin  in  the  muscular  coat.  The  characters  of  myoma  and 
fibroma  may  be  combined — ^myofibroma  or  fibromyoma.  These  essentially- 
benign  tumors  may  cause  hemorrhage:  they  are  more  vascular  here  than 
elsewhere,  but  the  chief  danger  lies  in  their  tendency  to  attain  a  size  suf- 
ficient to  block  up  the  bony  pelvis — much  after  the  fashion  of  uterine  tu- 
mors of  similar  nature.  The  resulting  pressure  on  contiguous  parts  may  do 
great  damage.    Pressure  upon  the  ureters  is  a  source  of  special  danger. 


762  NEOPLASMS,  OP    THE    BLADDEE. 

Such,  essentially-benign  growths  as  enchondroma,  lymphadenoma^  and 
angioma  have  been  met  with  in  the  bladder.  They  are  exceedingly  rare, 
and  unless  extensive,  or  located  at  points  wbere  obstruction  to  the  ureters 
or  vesical  outlet  is  produced,  are  exceedingly  benign.  Their  growth  is  usu- 
ally very  slow  and  productive  of  little  or  no  inconvenience  in  the  absence 
of  urinary  obstruction. 

Symptoms  of  the  Rarer  Forms  of  Benign  Vesical  Groivths. — These  tumors 
may  exist  for  years  without  symptoms.  Obviously,  most  of  the  symptomatic 
and  diagnostic  points  outlined  in  connection  with  vesical  papilloma  apply 
equally  well  to  the  other  forms  of  growth.  Hemorrhage  may  occur  in  any 
of  them,  though  not  with  such  constancy  and  severity  as  in  papilloma.  Press- 
ure symptoms  and  secondary  cystic  and  renal  disease  are  the  same  in  all, 
after  a  certain  size  is  attained.  In  the  solid,  firm,  slow-going  growths  press- 
ure symptoms  alone  may  exist. 

Diagnosis. — Palpation,  cystoscopy,  and  cystotomy,  with  digital  and 
ocular  inspection,  are  the  diagnostic  resources.  Particles  of  tumor-tissue 
are  rarely — in  some  varieties  never — found.  Palpation  and  rectal  explora- 
tion may  reveal  a  pelvic  tumor.  Vesical  exploration  with  the  Thompson 
searcher  may  reveal  the  tumor  jutting  into  the  bladder. 

MALIGNAXT   YESICAL    GEOWTHS. 

Saecoma. — Most  of  our  accurate  knowledge  of  vesical  sarcoma  is  to  be 
credited  to  Hurry  Fenwick,  whose  studies  of  fifty  cases  are  a  classic  upon 
the  subject,  i^ccording  to  him,  they  are  most  often  seen  in  children,  in 
whom  they  are  usually  multiple  and  polypoid  in  form.  In  the  adult  they 
are  more  often  single  and  broad-based:  i.e.,  sessile.  The  growths  are  gen- 
erally pure  sarcoma  and  may  attain  a  very  large  size.  Some  eases  show  a 
transitionary  stage  between  papilloma  and  sarcoma.  About  one-third  of 
Fen  wick's  cases  were  of.  the  small,  round-celled  variety.  Spindle-cells  pre- 
ponderated in  something  less  than  20  per  cent.  Sarcoma  of  the  bladder 
is  of  rapid  growth  and  therefore  tends  to  speedy  glandular  infiltration.  Sur- 
rounding tissues  and  organs  are  likely  to  become  involved.  Even  the  bony 
pelvis  may  be  attacked. 

Caecinoma. — Although  comprising  about  50  per  cent,  of  vesical  tu- 
mors, true  cancer  of  the  bladder  is  nevertheless  a  rare  affection,  and  as  a 
primary  disease  is  very  exceptionally  seen.  Most  often  it  is  secondary  to 
cancer  of  the  uterus,  penis,  rectum,  prostate,  testicle,  and  in  very  rare  in- 
stances the  kidney  or  other  remote  organ  or  tissue.  Involvement  of  the 
bladder  in  cancer  of  contiguous  tissues  is  naturally  to  be  anticipated,  and 
in  such  affections  as  epithelioma  af  the  cervix  uteri  it  is  very  often  a  com- 
plication late  in  the  course  of  the  case.  The  patient  wbo  dies  prior  to  the 
occurrence  of  such,  extension  of  the  disease  is,  indeed,  fortunate,  as  the 
bladder  complication  is  apt  to  inflict  indescribable  suffering.  In  general, 
vesical  cancer  is  most  frequent  in  men  above  middle  age. 


CAECINOMA    OF    THE    BLADDEE. 


763 


Of  the  yarities  of  cancer,  epithelioma  is,  perhaps,  the  one  that  most 
often  affects  the  bladder,  encephaloid  being  next  in  frequency,  and  scirrhus 
being  especially  rare. 

Inasmuch  as  nearly  all  neoplasms  of  the  bladder  are  fatal,  an  attempt 
has  been  made  to  include  sarcoma  and  papilloma  under  the  head  of  cancer; 
but  this  is  apt  to  prove  a  source  of  confusion.  The  apparent  malignancy 
of  the  non-cancerous  vesical  tumors  is  not  intrinsic,  but  is  due  to  certain 
anatomic  and  physiologic  peculiarities  of  the  affected  viscus. 

The  course  of  primary  vesical  cancer  is  extreme^  slow,  and  contiguous 
parts  are  rarely  invaded.  The  pelvic  glands  become  invaded  in  time,  but 
general  dissemination  of  cancer-cells  and  the  formation  of  secondary  neo- 
plastic foci  are  not  frequent.     Ulceration  is  rare.     Many  cases  go  through 


Fig.  157.- — Vesical  epithelioma.     (After  Moullin.) 


their  course  without  hematuria  unless  hemorrhage  is  induced  by  vesical 
exploration. 

The  slow  extension  and  infrequent  general  infection  of  vesical  cancer 
has  been  explained  by  the  sparsity  and  peculiar  arrangement  of  the  lym- 
phatic vessels  of  the  bladder. 

The  characteristic  feature  of  vesical  cancer  is  its  tendency  to  general 
infiltration  and  hardening  of  the  viscus.  In  the  author's  experience,  the 
growth  is  most  often  irregular,  nodulated,  and  presents  a  varying  propor- 
tion of  polypoid  and  sessile  outgrowths,  jutting  into  the  cavity  of  the  organ. 
This  condition  often  tempts  one  to  remove  the  apparently  easily  accessible 
projections.  Careful  intravesical  palpation,  however,  reveals  general  in- 
filtration of  the  vesical  wall  in  most  cases,  if  not  in  all. 


764 


XEOPLASMS  OF  THE  BLADDEE. 


Symptoms. — The  sjTuptoms  of  yesieal  cancer  are  in  no  sense  charac- 
teristic,  being,  in  a  general  way,  those  of  severe  and  intractable  chronic  ves- 
ical infiammation,  perhaps  with  obstruction.  Great  pain  is  apt  to  be  experi- 
enced, and  hemorrhages  usnally  occur  from  time  to  time.  The  patient 
finally  dies  from  exhaustion,  due  to  pain,  hemorrhage,  and  disturbed  rest, 
and  possibly  a  certain  degree  of  septic  absorption.  Uremia  may  be  a  factor 
in  the  fatal  result,  from  secondar}"  renal  disease. 

Diagnosis. — The  diagnosis  of  vesical  cancer  is  readily  made  when  a 
cancerous  growth  of  neighboring  tissues  is  known  to  exist.  Some  cases  are 
obscure,  and  require  cystoscopy  or  cystotomy  to  clear  up  the  diagnosis.  In 
general,  however,  the  severe  pain,  cachectic  appearance,  and  frequent  hema- 


Fig.  lo8. — Carcinoma  of  bladder.      (After  Albarran.) 


turia  are  sufficient  to  warrant  a  diagnosis  of  cancer.  Oftentimes  particles 
of  cancer-tissue  become  detached  and  appear  in  the  urine,  in  which  case 
the  microscope  will  settle  all  doubt  as  to  the  character  of  the  disease. 

Where  cancer  of  the  prostate  and  bladder  co-exist,  the  diagnosis  is  usu- 
ally readily  made  by  rectal  exploration  with  the  finger.  Xodulation  and 
hardness  of  the  prostate  and  base  of  the  bladder  are  quite  characteristic, 
especially  in  men  above  fifty  years  of  age.  In  vesical  cancer,  secondary  to 
malignant  disease  of  the  uterus,  the  diagnosis  is  easy.  Cancer  of  remote 
organs  or  tissues  makes  the  diagnosis  of  vesical  cancer  probable  where  sus- 
picious vesical  symptoms  exist. 

Teeatniext  of  Vesical  Tumoes. — The  treatment  of  tumors  of  the 
bladder  necessarily  varies  according  to  the  rapidity  and  location  of  the 


DIAGNOSIS    AND    TEEATMENT    OF    VESICAL   TUMOES. 


'65 


growth  and  the  period  at  which  the  diagnosis  is  made.  Where  operation  is 
refused  or  the  diagnosis  is  douhtful,  and  in  cases  coming  under  observation 
late  in  the  course  of  the  disease,  particularly  in  malignant  affections,  pallia- 
tion is  the  only  recourse. 

Palliative  Methods. — The  palliative  treatment  of  tumors  of  the  bladder 


Fig.  159. — Bladder  containing  medullary  cancer  complicated 
by  two  calculi.     (After  Coulson.) 

consists  of  measures  to  relieve  symptoms  incidental  to  secondary  conditions 
and  allay  pain.  Analgesic  measures  are  nearly  always  indicated  in  malig- 
nant vesical  disease,  and  are  sometimes  necessary  at  an  early  period.  In 
non-malignant  tumors,  however,  pain  is  not  a  prominent  symptom,  as  a 
rule,  until  the  growth  has  attained  considerable  size:   sufficient,  at  least,  to 


Fig.  160. — Nitze-Leiter  cystoscope. 


produce  pressure  upon  sensitive  surrounding  parts  or  nervous  structures 
traversing  them.  An  exception  must  be  made  to  this  rule  in  cases  in  which 
the  tumor  occupies  such  a  position  that  the  vesical  neck  is  encroached  upon, 
thus  producing  frequent  and  painful  micturition.  Under  such  circum- 
stances a  tumor  of  very  small  size  may  give  rise  to  such  painful  symptoms 


766  NEOPLASMS  OF  THE  BLADDER. 

and  such  marked  disturbance  of  the  function  of  urination  that  anodynes 
and  antispasmodics  become  necessary  at  a  very  early  period. 

Cystitis  arises  sooner  or  later  in  the  majority  of  cases  of  vesical  tumor, 
its  period  of  development  depending  largely  upon  the  frequency  and  septic 
qualities  of  instrumental  interference  with  the  organ.  In  a  general  way, 
interference  with  the  bladder,  short  of  radical  operative  measures,  is  to  be 
avoided  as  long  as  possible  in  vesical  tumors.  When  instrumental  explora- 
tion becomes  necessary  extreme  care  should  be  taken  not  to  infect  the 
urinary  tract.  When  infection  occurs  the  misery  of  the  patient  is  greatly 
increased.  The  measures  for  the  treatment  of  cystitis  indicated  in  tumors 
of  the  bladder  are  precisely  similar  to  those  employed  in  vesical  inflamma- 
tion under  other  circumstances. 

Secondary  involvement  of  the  kidneys — pyelonephritis — may  often  be 
avoided  by  caution  in  the  matter  of  vesical  exploration;  or,  if  infection  of 
the  bladder  has  already  occurred,  by  careful  antiseptic  irrigations  of  that 
viscus  combined  with  appropriate  internal  urinary  antiseptics.  Should, 
however,  renal  complications  occur  from  extension  of  the  infectious  process 
upward  along  the  ureters. to  the  renal  pelvis,  and  thence  to  the  secretory 
structure  of  the  kidney,  the  measures  ordinarily  employed  for  relieving 
renal  strain  by  vicarious  elimination  through  the  medium  of  the  skin  and 
bowels  are  indicated,  together  with  such  local  measures  in  the  way  of 
anodyne  applications  and  hot  fomentations  over  the  region  of  the  kidneys 
as  may  be  required.  Dietetic  management  is  as  important  here  as  under 
other  conditions  of  renal  disease,  with  due  regard  for  the  extremely  debili- 
tating tendency  of  malignant  vesical  disease,  which  renders  caution  in  the 
matter  of  dietetic  restriction  necessary. 

Hemorrhage  is  a  very  important  complication  of  neoplasms  of  the  blad- 
der. In  a  general  way,  it  does  not  require  special  treatment  unless  the 
hematuria  is  sufficiently  severe  to  be  immediately  threatening,  or  by  the 
production  of  chronic  anemia.  In  the  lesser  degrees  of  hematuria  both  in- 
ternal and  local  measures  of  hemostasis  are  likely  to  be  productive  of  more 
injury  than  the  hemorrhage  is  if  let  alone.  The  various  internal  and  local 
remedies  for  urinary  hemorrhage  in  general  have  already  been  presented  in 
the  chapter  on  hematuria. 

In  hematuria  from  vesical  tumors,  cystotomy  and  packing  the  bladder, 
or  such  operations  as  may  be  practicable  for  the  radical  removal  of  the 
source  of  hemorrhage,  must  be  especially  borne  in  mind.  When  the  blad- 
der is  opened  for  the  purpose  of  hemostasis,  the  surgeon  should  be  prepared 
to  perform  a  radical  operation  if  such  be  warrantable. 

Radical  Treatment. — In  all  cases  in  which  the  diagnosis  is  made  at  an 
early  period,  cystotomy,  for  the  purpose  of  exploration  and,  if  practicable, 
removal  of  the  neoplasm,  is  imperatively  indicated.  There  should  be  no 
delay  when  once  the  diagnosis  is  established,  and  whenever,  on  opening  the 
bladder,  the  tumor  is  found  to  be  accessible,  it  should  be  removed.    Modern 


TEEATMENT  OF  NEOPLASMS  OF  THE  BLADDEK.  767 

surgery  has  shown  that  it  is  perfectly  feasible  to  remove  practically  the 
entire  bladder  in  cases  of  vesical  tumor,  the  ureters  being  transplanted  into 
the  rectum  or  sigmoid  flexure.  This  class  of  surgery  is  certainly  bold  enough, 
and  exemplifies  the  wonderful  progress  that  surgery  has  made  in  recent  years. 
There  is  a  question  in  the  author's  mind,  however,  as  to  whether  we  are  ever 
Justified  in  performing  such  an  extensive  operation  in  hopeless  cases,  when 
the  result  of  the  operation,  even  if  the  patient  lives,  is  at  best  a  condition 
of  affairs  that  is  quite  as  bad  as  the  one  for  which  the  operation  is  per- 
formed. Complete  extirpation  of  the  bladder  in  malignant  disease  is  never 
curative.  It  has  been  suggested  as  a  means  of  prolonging  life  and  making 
the  patient  more  comfortable.  With  cocain  and  morphin  at  our  command, 
however,  this  argument  is  not  a  very  logical  one.  The  author  does  not  wish 
to  assume  a  dogmatic  position  on  this  point,  as  there  are  exceptions  to  all 
surgical  rules,  and  surgical  procedures  must  be  modified  accordingly.  But, 
in  a  general  way,  the  foregoing  statement  is  by  no  means  too  radical. 

Tumors  of  the  bladder  may  be  attacked  either  suprapubically  or  peri- 
neally,  or  both,  as  conditions  may  demand.  In  a  general  way,  where  one 
route  alone  is  resorted  to,  suprapubic  section  is  best.  Suprapubic  section 
for  the  removal  of  tumors  of  the  bladder  is  in  nowise  different  from  that 
employed  under  other  circumstances,  save  that  more  room  is  usually  re- 
quired than  in  other  conditions  of  the  bladder  demanding  operation.  This 
extra  room  may  be  acquired  by  the  cross-section  of  Trendelenburg,  with  or 
without  symphysiotomy.  A  useful  method  of  cross-section  is  to  remove  a 
part  of  the  superior  border  of  the  pubes  with  the  tendinous  insertions  of  the 
recti  muscles  intact;  a  quadrangular  flap  can  thus  be  lifted  up  in  such  a  man- 
ner that,  when  the  bony  fragment  is  wired  to  the  body  of  the  bone  at  the 
is  exposed,  are  governed  entirely  by  the  location,  size,  and  conformation  of 
conclusion  of  the  operation,  hernia  is  not  likely  to  occur. 

The  operative  procedures  necessary,  when  the  interior  of  the  bladder 
the  tumor.  Small  pedunculated  tumors  are  very  often  readily  twisted  off. 
This  is  an  excellent  plan  for  the  management  of  simple  growths,  especially 
those  fibro-adenomatous  neoplasms  situated  about  the  vesical  neck,  which 
sometimes  constitute  the  entire  trouble  in  chronic  prostatic  disease.  Where 
small  pedunculated  growths  are  met  with,  and  there  is  suspicion  of  malig- 
nancy, the  tissue  underlying  the  tumor  at  its  base  should  be  excised  with 
the  growth,  the  resulting  wound  being  sutured  where  practicable.  Care 
should  be  taken  to  remove  a  sufficient  amount  of  vesical  mucous  membrane 
and  submucous  tissue  to  insure  the  entire  removal  of  the  growth,  with  due 
consideration  for  the  vesical  deformity  that  the  resulting  cicatrix  is  liable 
to  make.  While  the  surgeon  should  be  very  careful  to  remove  all  the 
diseased  tissue,  he  is  not  warranted  in  so  liberal  a  construction  of  this 
principle  as  he  is  in  some  other  situations.  In  some  cases  the  fingers  are 
sufficient  to  twist  off  small  benign  growths;  in  others  it  is  necessary  to  use 
the  ecraseur,  galvanocautery,  or  some  of  the  various  forms  of  rongeur  for- 


768  XEOPLASMS  OF  THE  BLADDEE. 

ce|)s  devised  for  intravesical  work.  The  curette,  or  sharp  spoon,  is  some- 
times useful,  especially  in  villous  growths.  The  finger-nail  is  often  suffi- 
cient for  scraping  off  papillomata.  The  galvanocautery  should  always  be 
applied  to  the  base  of  papillomata  after  their  removal.  If  the  operation  is 
not  thorough,  it  not  only  fails  of  its  object,  but  a  new  stimulus  is  afforded 
for  further  morbid  growth,  and  recurrence  is  certain. 

A  point  that  is  very  striking  to  the  inexperienced  operator  is  the  small 
size  of  some  tumors  that  have  given  rise  to  severe  hematuria.  A  growth 
no  larger  than  a  raspberry  has  been  known  to  cause  alarming  hemorrhage. 

In  sessile  growths  the  rongevir  forceps,  fingers,  and  curette,  singly  or 
combined,  may  be  used.  In  many  instances  the  tumor  can  only  be  removed 
piecemeal.  Great  care  should  be  taken  to  remove  every  particle  of  the  neo- 
plasm and  to  produce  as  little  laceration  and  bruising  of  the  normal  tissues 
as  possible.  In  some  malignant  growths  the  actual  cautery  or  galvano- 
cautery may  be  used  after  their  removal,  the  base  of  the  tumor  being 
thoroughly  cauterized  for  the  purpose  not  only  of  cheeking  hemorrhage, 
but  of  destroying  any  small  portions  of  the  new  growth  that  may  be  left 
by  excision  or  avulsion.  The  carbonized  eschar  left  by  the  application  of 
the  cautery  renders  the  wounded  surface  very  much  less  liable  to  infection 
than  where  a  raw  wound  is  left.  In  intravesical  suturing  carefully-pre- 
pared chromicized  catgut  should  be  used.  Absorbable  sutures  are  abso- 
lutely necessary,  because  other  forms  tend  to  become  incrusted  with  phos- 
phatic  deposit,  forming  nuclei  for  the  subsequent  formation  of  calculus. 
Hemorrhage  after  operation  may  be  controlled  by  packing  the  bladder,  or, 
as  just  suggested,  the  actual  cautery.  In  some  instances  packing  the  neck 
of  the  bladder  about  a  firm  perineal  tube  is  all  that  is  necessary.  A  peri- 
neal houtonniere  and  the  insertion  of  the  tube  are  best  as  a  secondary  feature 
of  the  suprapubic  operation  where  the  tumor  is  small  and  located  at  the 
vesical  neck  and  hemorrhage  is  troublesome.  Hot  water  is  often  effective 
in  checking  hemorrhage  after  the  operation.  Oozing  or  obstinate  hematuria 
after  the  completion  of  the  operation  ma}'  often  be  controlled  b}^  the  internal 
administration  of  turpentine  emulsion. 

The  after-treatment  of  operations  for  the  removal  of  vesical  tumors 
is  the  same  as  regards  urinary  antisepsis,  both  local  and  internal,  as  in  other 
operations  upon  this  portion  of  the  genito-urinary  tract. 

Electric  illumination  of  the  bladder  via  the  suprapubic  wound  in 
vesical  explorations  or  operations  is  often  exceedingly  useful.  Small  port- 
able lamjDS  have  been  devised  for  iUuminating  the  cavities  of  the  body  that 
are  especially  useful  in  the  diagnosis  and  operative  treatment  of  vesical 
tumors. 

VESICAL    CYSTS. 

Cysts  or  sacculi  of  the  bladder  are  usually  seen  in  elderly  men,  in  asso- 
ciation with  general  vesical  hypertroph}'  due  to  obstructive  affections  of  the 


YESICIAL    CYSTS. 


769 


prevesical  portion  of  the  genito-urinary  tract.  These  obstructive  affections 
— of  which  urethral  stricture^  enlarged  prostate,  and  vesical  calculus  are 
examples — necessitate  severe  straining  during  the  frequent  acts  of  mic- 
turition that  the}^  invariably  produce.  The  muscular  fasciculi  of  the  vesical 
walls  are  deficient  in  certain  localities,  and,  as  a  natural  consequence,  the 


Fig.  161. — Sacculation  of  bladder. 

bladder  is  relatively  weak  at  such  points.  As  the  bundles  of  muscular  fibers 
undergo  compensatory  hypertrophy,  the  fibers  in  these  weak  areas  either 
yield  or  separate,  and  the  fibrous  and  peritoneal  coats  of  the  viscus  are 
pouched  out  b}^  the  urine,  thus  forming  a  sacculus,  or  pseudocyst.     These 


Fig.  162. — Sacculation  of  bladder,  showing  sac  cut  open. 


^ 


cysts  vary  in  size  from  the  dimensions  of  a  cherry  to  those  of  a  large  orange: 
cases  have  been  noted  in  which  the  cyst  was  as  large,  or  larger,  than  the 
bladder  itself.  Congenital  simple  and  dermoid  vesical  cysts  are  also  met 
with,  but  very  rarely. 

In  women  a  peculiar  form  of  vesical  protrusion  known  as  cystocele  is 
apt  to  occur.     This  consists  of  a  prolapse  of  the  vesico-vaginal  septum. 


770  VESICAL    TUBERCULOSIS. 

forming  a  globular  tumor  upon  the  anterior  wall  of  the  vagina,  which,  in 
some  cases,  protrudes  from  the  vulvar  orifice.  This  protrusion  is  due  to 
weakness,  or  rupture,  of  the  perineal  body,  and  a  consequent  lack  of  sup- 
port to  the  vaginal  walls.  The  anterior  wall,  as  it  sags  downward,  drags 
the  bladder  with  it,  forming  a  tumor  of  a  pseudocystic  character,  the  cavity 
of  which  is  continuous  with  that  of  the  bladder. 

There  is  a  peculiar  condition  not  infrequently  met  with  in  female  chil- 
dren that  the  surgeon  must  bear  in  mind:  As  a  consequence  of  laxity  of  the 
vesical  walls,  associated  with  a  patulous  urethra,  the  bladder  inverts,  form- 
ing a  tumor — apparently  cystic — protruding  from  the  meatus.  A  mistake 
in  diagnosis  would  prove  a  serious  matter.  The  treatment  in  such  cases  is 
obviously  not  excision,  but  reduction  followed  by  urethroplasty  to  narrow 
the  canal  and  prevent  recurrence  of  the  prolapse. 

Vesical  cysts,  while  innocuous  in  themselves,  are  apt  to  lead  to  serious 
complications  of  chronic  urinary  disease.  Inasmuch  as  such  cysts  are  not 
invested  with  any  appreciable  amount  of  muscular  tissue,  they  are  inelastic, 
and  consequently  never  empty  themselves  of  urine.  The  residual  urine  de- 
composes and  the  bacteria  and  toxins  involved  in  the  decomposition  impart 
irritating  properties  to  the  entire  contents  of  the  bladder,  thus  perpetuating 
inflammation.  On  this  account,  chronic  cystitis,  complicated  by  vesical 
sacculi,  cannot  be  cured,  as  it  is  impracticable  to  remove  them.  Again, 
the  decomposition  of  the  residual  urine  of  the  sacculus  produces  a  deposi- 
tion of  triple  phosphates,  and  these  crystallizing  about  a  gout  of  mucus,  or 
perhaps  a  small  uric-acid  nucleus  that  has  lodged  in  the  sacculus,  form  an 
encysted  calculus.  Such  calculi  are  very  difficult  of  detection,  and  still 
more  difficult  of  removal. 

In  addition  to  the  danger  of  calculous  deposit,  the  extreme  tenuity  of 
vesical  sacculi  entails  great  liability  to  rupture:  an  accident  that  leads  to 
one  or  the  other  of  such  inevitably  fatal  complications  as  pelvic  extravasa- 
tion, cellulitis  and  gangrene,  and  peritonitis. 

The  diagnosis  of  vesical  cysts  and  sacculi  can  only  be  made  by  the 
cystoscope,  or  cystotomy  and  direct  exploration. 

The  treatment  of  vesical  cysts  is  decidedly  unsatisfactory,  and  consists 
chiefly  in  palliation  of  co-existent  C3''stitis  and  removal  of  the  obstructive 
cause  of  the  vesical  protrusion.  Encysted  calculi  may  sometimes  be  re- 
moved, but  in  the  majority  of  cases  are  not  detected  until  after  death.  The 
early  removal  of  urinary  obstruction  will  always  prevent  the  formation  of 
cysts  and  sacculi. 

VESICAL    TUBEECULOSIS. 

Tuberculosis  of  the  bladder,  occurring  as  an  entity,  is  a  condition  that 
is  very  rarely  met  with.  When  it  does  occur  it  is  nearly  always  the  result 
of  secondary  infection,  the  primary  condition  being  either  general  tuber- 
culosis or  a  more  or  less  extensive  involvement  of  the  senito-urinarv  tract 


I 


VESICAL    TUBEECULOSIS.  771 

as  a  whole.  Local  tuberculosis  of  distant  parts — for  example,  of  the  lungs 
— is  not  so  likely  to  be  followed  by  vesical  infection  as  is  general  tuber- 
culosis. Heredity-  bears  an  important  relation  to  vesical  tuberculosis,  al- 
though it  is  not  so  po'tent  a  factor  as  in  the  pulmonary  form.  Victims  of 
uro-genital  tuberculosis  are  often  of  excellent  heredity  and  exce23tionally 
robust  physique. 

Primary  tuberculosis  of  the  bladder  is  so  rarely  seen  that  we  are  always 
justified  in  susjoecting  that  the  original  focus  has  been  overlooked  in 
alleged  primary  cases.  It  must  be  acknowledged,  however,  that  aj)parently- 
well-authenticated  cases  have  been  observed.  Primary  tubercular  infection 
of  the  genito-urinary  tract  as  a  whole  is  by  no  means  infrequent;  indeed, 
it  occurs  far  more  frequently  than  is  generally  supposed.  It  is  hardly  con- 
ceivable that  the  bacilli  of  tuberculosis  ever  limit  themselves  to  any  par- 
ticular portion  of  the  mucous  membrane,  for  the  susceptibility  and  con- 
tinuity of  the  mucous  lining  of  the  entire  tract  must  be  granted.  J^umer- 
ous  cases  occur,  however,  in  which  there  is  comparatively  slight  disturbance 
of  the  function  of  micturition  and  a  relatively  mild  degree  of  inflammation 
of  the  mucous  membrane.  The  urine  is  nevertheless  found,  when  centri- 
fuged,  to  contain  tubercle  bacilli,  perhaps  in  large  numbers.  The  author 
is  of  opinion  that  man}'  apparently  mild  eases  of  catarrh  of  the  genito- 
urinary tract  are  really  instances  of  tubercular  infection  of  the  mucous 
membrane.  It  is  by  no  means  a  necessary  result  of  the  tubercular  infection 
that  prominent  symptoms  or  a  rapidly  fatal  course  of  the  disease  should 
occur.  Clinical  observation  Avould  seem  to  show  that  genito-urinary  tuber- 
culosis per  se,  as  compared  Avith  other  forms  of  the  disease,  is  relatively 
mild,  and  it  is  perfectly  possible  for  the  disease  to  limit  itself  to  the  super- 
ficies of  the  mucous  membrane  for  a  prolonged  period  without  producing 
distressing  symptoms.  The  bacillus  tuberculosis  may  be  found  in  the  urine 
in  cases  of  genito-urinary  infection  for  a  prolonged  period  before  serious 
symptoms  occur,  and,  after  the  disease  has  been  controlled  to  a  great  extent 
and  symptoms  thereby  considerably  allayed,  the  urine  may  still  contain 
a  moderate  amount  of  muco-pus  associated  with  a  large  number  of  tubercle 
bacilli.  This  condition  may  go  on  indefinitely  without  producing  symp- 
toms. There  is  constant  danger,  however,  that  in  the  presence  of  a  locus 
minoris  resistentice,  afi^orded  by  exposure  to  cold,  highly-acid  urine,  debility 
from  any  cause  whatsoever,  or  trauma  of  the  mucous  membrane,  acute 
tubercular  infection  may  involve  the  deeper  structures  of  the  genito-urinary 
tract  and  go  on  to  a  serious  or  even  fatal  result.  The  focus  of  infection  in 
vesical  tuberculosis  may  be  above  or  below  the  bladder;  in  other  words,  the 
renal  pelvis,  on  the  one  hand,  or  the  prostate,  urethra,  or  seminal  vesicles, 
upon  the  other,  may  be  the  primary  source  of  the  infection.  Tubercu- 
losis of  the  bladder  occasionally  occurs  in  women  by  secondary  infection 
from  tubo-ovarian  tubercular  disease.  Vesical  tuberculosis  is  rare,  how- 
ever, in  the  female.    This  is  in  harmony  with  the  fact  that  renal  tuberculosis 


772  SYMPTOMS    OF    VESICAL    TUBERCULOSIS. 

is  rare  in  women.  Descending  infection  occurs  very  much  more  speedily 
than  ascending  infection,  other  conditions  being  equal,  and  for  obvious 
reasons.  The  author  desires  to  lay  especial  stress  on  the  clinical  observa- 
tion that  tubercle  bacilli  may  exist  in  the  urine  in  mild  cases  of  apparently 
simple  infection  of  the  mucous  membrane  of  the  genito-urinary  tract.  Mild 
catarrhal  states  and  conditions  of  apparently  simple  inflammation  should  be 
investigated  more  frequently  than  is  the  prevalent  custom.  If  this  be  done 
and  the  centrifuge  be  used,  it  is  probable  that  tubercular  infection  of  the 
mucous  membrane  of  the  urinary  tract  will  be  found  to  be  very  much  more 
frequent  than  is  generally  supposed. 

The  primary  focus  of  infection  has  been  the  subject  of  dispute.  In  a 
series  of  fifty  cases  of  vesical  tuberculosis  studied  by  Hamill,  the  primary 
lesion  was  in  the  kidney.  Opinions  differ  as  to  the  most  frequent  primary 
source  of  infection  in  the  adult.  In  the  authors  experience  the  order  of  fre- 
quency has  been:  first,  the  lungs;  second,  the  prostate;  third,  the  kidneys. 
As  Martin  says,  however,  the  infection  of  the  bladder,  prostate,  and  kidney 
may  be  simultaneous. 

Morbid  Anatomy. — The  appearances  of  the  bladder  in  vesical  tuber- 
culosis vary.  In  some  cases  a  large  number  of  miliary  deposits  are  found, 
scattered  over  a  considerable  area.  In  others  there  is  a  deposit  of  relatively 
large  masses  of  tubercular  granuloma.  The  deposit  shows  a  special  pre- 
dilection for  the  trigone  and  base  of  the  bladder.  The  vicinity  of  the  ure- 
thral orifices  is  often  the  focal  point  of  the  deposit.  Breaking  down  of  the 
neoplasm  with  resultant  ulceration  occurs  sooner  or  later. 

Symptoms. — The  symptoms  of  tuberculosis  of  the  bladder  are  in  no- 
wise characteristic.  Being  those  of  chronic  inflammation,  the  symptoms 
necessarily  vary  (1)  with  the  character  of  the  local  conditions,  (2)  with 
their  location,  and  (3)  the  stage  of  advancement  of  the  tubercular  process. 
AVhen  the  primary  seat  of  the  disease  is  in  the  prostate  or  in  the  vicinity 
of  the  vesical  neck,  the  function  of  micturition  is  disturbed  at  a  very  early 
period.  The  same  is  true  of  cases  in  which  descending  infection  results  in 
tubercular  disease  of  the  prostatic  urethra  and  seminal  vesicles.  In  many 
cases  in  which  the  prostate  is  involved,  slight  hemorrhages  occurring  from 
time  to  time  may  be  the  first  symptom  noticeable;  hematuria  may  be  the 
only  manifestation  of  disease  of  the  urinary  tract  for  a  long  time.  The  fol- 
lowing case  illustrates  this: — 

Case. — A  young  man,  35  years  old.  applied  for  treatment  for  hematuria  that  had 
occurred  at  variable  intervals  for  three  or  four  weeks.  The  bleeding  was  almost 
entirely  limited  to  the  beginning  and  end  of  the  act  of  micturition.  Associated  with 
this  symptom  there  was  more  or  less  debility  and  anemia  with  anorexia.  There  were 
no  chills,  fever,  or  sweating.  Examination  showed  a  distinct  contraction  at  the  bulbo- 
membranous  junction.  This  was  treated  by  dilation  and  the  hemorrhages  tempo- 
rarily improved.  The  bladder,  however,  became  irritable,  the  irritability  growing 
steadily  worse  and  the  general  condition  of  the  patient  retrograding  proportionately. 
Examination  of  the  urine  revealed  tubercle  bacilli  in  large  numbers.    Under  treatment 


DIAGNOSIS    AND    TEEATMENT    OF    VESICAL    TUBEECULOSIS.  773 

this  patient  regained  his  general  health  and  the  bacilli  temporarily  disappeared  from 
the  urine.  They  have  retumed,  however,  and  at  the  last  examination  were  quite 
abundant.  The  patient  declines  to  be  treated  further,  because  he  has  no  symptoms. 
He  has  been  free  from  symptoms  now  for  nearly  a  year. 

Frequent  and  painful  micturition,  perhaps  bloody  urine,  general  de- 
bility, and  possibly  emaciation,  associated  with  purulent  urine,  constitute 
sufficient  ground  for  suspicion  of  tubercular  infection,  especially  if  there 
is  a  history  of  heredity.  Ulceration  is  likely  to  occur  after  a  time,  in  which 
event  the  severity  of  the  symptoms  increases. 

Diagnosis. — The  only  certain  methods  of  establishing  a  diagnosis  of 
tuberculosis  of  the  urinary  tract  are  (1)  the  discovery  of  tubercle  bacilli 
in  the  urine,  and  (2)  successful  inoculation  of  animals  with  the  urinary 
sediment. 

In  many  cases  in  which  the  symptoms  are  severe  and  the  urine  con- 
tains a  large  amount  of  pus  no  bacilli  can  be  found,  even  when  the  urine 
is  examined  with  the  utmost  care.  The  importance  of  the  centrifuge  in 
examination  of  the  urine  for  the  purpose  of  determining  the  existence  of 
tubercle  bacilli  cannot  be  overestimated.  By  its  use  the  bacilli  may  be 
found  in  tubercular  cases  at  a  much  earlier  period  than  has  hitherto  been 
possible.  Obviously,  when  ulceration  occurs,  there  is  much  greater  prob- 
ability of  tubercle  bacilli's  being  present  in  the  urine  than  at  an  earlier 
period.  Where  the  bladder  will  tolerate  the  presence  of  four  or  five  ounces 
of  urine  it  is  often  possible  to  establish  the  precise  seat  of  the  disease  by 
means  of  the  cystoscope.  A  knowledge  of  the  existence  of  general  tuber- 
culosis makes  the  diagnosis  almost  certain  in  suspicious  cases,  unless  other 
sources  of  vesical  infection  and  inflammation  be  established.  The  existence 
of  tubercular  disease  of  the  urethra,  prostate,  or  renal  pelvis  makes  assur- 
ance doubly  sure  when  marked  symptoms  referable  to  the  bladder  exist. 
In  suspicious  cases  where  bacilli  cannot  be  found  the  urinary  sediment 
should  be  injected  in  the  cellular  tissue  of  a  guinea-pig.  If  the  sediment 
contains  tubercle  bacilli,  general  infection  of  the  animal  will  occur  within 
three  or  four  weeks. 

Treatment.  —  The  treatment  of  vesical  tuberculosis  consists  of  (1) 
general  measures  to  combat  tubercular  infection  and  the  nutritional  dis- 
turbances incidental  to  it,  and  (2)  local  measures,  with  two  aims  in  view: 
(a)  to  destroy,  the  tubercle  bacilli;  (h)  to  relieve  the  conditions  secondary 
to  tubercular  infection,  which  conditions,  as  is  well  known,  are  largely 
the  result  of  secondary  mixed  infection. 

General  Treatment. — The  general  measures  involved  are  the  same  as 
those  employed  in  tuberculosis  elsewhere  with  respect  to  nutritious  food, 
fresh  air,  exercise,  and  change  of  climate,  associated  with  such  remedies  as 
codliver-oil,  iron,  hypophosphites,  and  the  hypodermic  administration  of 
the  nucleins  or  Koch's  tuberculin.  Tuberculin,  prepared  according  to 
Koch's  old  formula,  is  used  but  little  at  the  present  time  save  for  diagnostic 


774  TEEATMENT    OF    VESICAL    TUBEECULOSIS. 

purposes^,  for  which  it  has  a  certain  value.  It  is  not,  of  course,  to  be  used 
for  this  purpose  excejoting  in  cases  in  which  the  microscope  fails  to  deter- 
mine bacilli  and  the  symptoms  warrant  a  strong  suspicion  of  tubercular 
disease.  The  newer  form  of  Koch's  tuberculin — tuberculin-R — has  given 
excellent  results  in  genito-urinary  tuberculosis.  With  respect  to  the 
modern  general  treatment  of  tuberculosis  of  the  genito-urinary  tract,  the 
author  will  cite  the  cases  of  two  medical  men  who  have  been  cured  of  this 
form  of  tuberculosis  by  the  use,  respectivelj^,  of  nuclein  and  tuberculin-E. 

Local  Treatment. — In  many  cases  palliation  only  is  possible.  Palliative 
measures  consist  in  the  administration  of  anodynes  to  relieve  pain  and 
vesical  spasm,  with  diluents  for  the  urine  and  remedies — local  and  inter- 
nal— calculated  to  allay  cystitis.  These  remedies  have  already  received 
attention. 

A  distinctly  curative  remedy  which,  although  administered  internalh', 
acts  in  all  probability  only  by  virtue  of  its  local  influence  over  the  infected 
tissues,  is  guaiacol.  This  may  be  given  in  the  form  of  the  pure  drug  in 
doses  of  3  or  3  minims,  three  or  four  times  daily  after  eating,  or  as  the 
carbonate  of  guaiacol,  in  doses  of  5  grains,  three  or  four  times  daily.  In_ 
the  author's  experience  guaiacol  is  an  excellent  remedy  in  all  forms  of  in- 
fectious inflammation  of  the  genito-urinary  tract.  In  a  general  way,  local 
measures  for  the  treatment  of  vesical  tuberculosis  should  be  as  mild  as  pos- 
sible. Indeed,  the  behavior  of  the  bladder  under  even  moderately  strong 
solutions  of  silver  nitrate  is  often  of  diagnostic  importance.  Xitrate-of- 
silver  solution  relieves  other  forms  of  vesical  inflammation,  but  markedly 
aggravates  the  variety  due  to  tubercular  infection.  Mild  solutions  of  boric 
acid,  biborate  of  soda,  and  carbolic  acid  are  best  for  irrigation  purposes. 
Where  it  is  possible  to  irrigate  the  bladder  without  the  use  of  a  tube  or 
catheter  by  simple  hydrostatic  pressure,  it  is  better  to  do  so,  as  the  danger 
of  rapid  tissue-destruction  and  perhaps  general  infection  is  directly  pro- 
portionate to  the  amount  of  traumatism  to  which  the  affected  parts  are 
subjected  in  the  introduction  of  instruments  of  any  kind  whatever. 

Guyon's  method  of  treatment  of  vesical  tuberculosis  consists  of  daily 
instillations  of  mercuric  chlorid,  beginning  with  1  to  5000  and  gradually 
increasing  to  1  to  1000.  This  is  highly  extolled  by  some  writers.  The 
bladder  should  be  gently  irrigated,  .without  painful  distension,  to  remove 
pathologic  material  from  the  mucous  membrane.  The  bichlorid  solution 
in  the  quantity  of  1  to  2  drams  is  then  injected.  The  author  has  not  had 
very  encouraging  results  from  the  method,  but  it  appears  worthy  of  further 
trial. 

Anodyne  injections  into  the  bladder  are  sometimes  beneficial  in  allay- 
ing pain  and  vesical  irritation.  Great  care  should  be  taken,  however,  in 
advanced  cases,  lest  ulceration  be  present  and  strong  narcotic  drugs  be 
thereby  absorbed  Avith  serious  or  even  fatal  results.  Anodyne  rectal  sup- 
positories are  very  ef&cacious  in  relieving  vesical  pain  and  spasm.     An 


TKEATMENT    OF    VESICAL    TUBERCULOSIS.  775 

important  point  to  be  gained  by  the  use  of  anodynes  is  to  promote  rest  of 
the  affected  organ.  Specific  medication  of  the  bladder  is  occasionally  very 
serviceable.  A  combination  of  iodoform,  albolene,  and  ether  has  given  the 
best  results  in  the  authors  hands.  Weak  solutions  of  chlorid  of  zinc  are 
sometimes  of  service.  Pure  guaiacol  instillations  are  often  of  great  service. 
Picot's  formula  for  the  local  use  of  guaiacol  is  an  excellent  one.  It 
is  as  follows: — 

IJ.  Guaiacol 5  parts. 

Iodoform   1  part. 

Sterilized  olive-oil 100  parts. 

M.    Sig. :    Inject  from  10  to  20  drops  into  the  bladder  once  or  twice  a  day. 

In  cases  in  which  the  palliative  measures  already  outlined  are  not  ef- 
fective,  it  may  become  necessary  to  perform  suprapubic  cystotomy  for  the 
purpose  of  obtaining  a  complete  rest  for  the  affected  viscus.  In  some  in- 
stances the  formation  of  a  permanent  suprapubic  fistula  is  a  great  boon  to 
the  patient,  and  it  is  not  unusual  in  subjects  whose  nutrition  is  fairly  good 
to  obtain  not  only  great  relief  of  the  local  symptoms,  but  marked  improve- 
ment in  the  general  condition  by  prolonged  suprapubic  drainage. 

Radical  Treatment. — In  a  general  way,  operative  measures  for  the 
radical  cure  of  tuberculosis  of  the  bladder  are  not  to  be  thought  of,  for 
the  reason  that  the  disease  is  so  extensive  that  it  involves  associated  tissues 
and  organs,  and  it  is  impossible  to  remove  all  of  the  foci.  To  seriously  con- 
sider a  radical  operation  in  eases  in  which  general  systemic  tubercular  in- 
fection exists  would,  of  course,  be  little  short  of  malpractice.  Should  it  be 
shown  at  an  early  stage  of  the  disease  that  the  tubercular  infection  is  lim- 
ited to  a  relatively  small  area  of  the  bladder,  which  area  is  accessible  supra- 
pubieally,  radical  measures — curettage  or  excision — may  then  be  considered. 


CHAPTEE  XXXIV. 

URINARY  CALCULUS. 

The  Lithic,  Oxalueic,  and  Phosphatic  Diatheses. 
Vesical  CALcrLus. 

Geneeal  Consideeations. — The  subject  of  urinary  calculus  is  of  the 
greatest  importance  to  the  practical  surgeon,  not  only  because  of  the  gravity 
and  delicacy  of  the  surgical  measures  for  its  relief,  but  because  its  study 
involves  the  consideration  of  a  large  number  of  local  and  constitutional 
conditions.  An  illustration  of  this  fact  is  the  intimate  relation  existing 
between  calculous  disease  and  both  inflammatory  and  obstructive  diseases 
of  the  genito-urinary  tract.  The  close  association  of  calculous  conditions 
with  various  morbid  constitutional  states,  shows  the  important  bearing  of 
the  subject  upon  general  medicine. 

The  urine  is  liable  to  the  deposition  of  various  solid  matters  in  numer- 
ous forms,  such  deposit  occurring  in  a  large  proportion  of  cases  as  a  result 
of  malassimilation  and  perversions  of  nutrition.  As  a  consequence  of  such 
conditions  an  excess  of  waste-materials  of  a  solid  or  crystalline  character 
is  eliminated  by  the  kidneys.  While,  as  a  rule,  these  materials  are  held  in 
solution,  they  may,  under  certain  circumstances,  become  gradually,  or  even 
suddenly,  crystallized. 

Etiology. — The  causes  of  this  excess  of  crude  and  imperfectly  elabo- 
rated materials  in  the  urine  are  several,  and  may  be  classified  briefly  as  fol- 
lows: 1.  A  disproportion  between  the  amount  of  material  ingested  in  the 
form  of  food  and  nutriment,  and  that  which  is  actually  needed  in  the  proc- 
ess of  tissue-repair,  leaving  a  surplus  to  accumulate  in  the  blood  and  tis- 
sues that  finally  finds  its  way  into  the  urine.  2.  A  marked  excess  of  ni- 
trogenized  material  in  the  food,  combined  with  insufficient  exercise.  3. 
The  excessive  imbibition  of  alcoholics  and  malt  liquors.  These  act  in  two 
ways,  viz.:  (a)  by  affording  an  excess  of  nutritive  material;  (&)  by  irri- 
tating the  digestive  organs,  particularly  the  liver,  and  the  organs  of  excre- 
tion. Thus,  alcohol  not  only  impairs  digestion  and,  secondarily,  assimila- 
tion, but  causes  a  strain  upon  the  kidney  that  results  in  a  strong,  highly- 
concentrated,  and  readily-crystallizable  urine.  4.  Eapid  tissue-waste,  gen- 
eral or  special,  arising  from  various  pathologic  conditions.  5.  Essential  im- 
pairment of  the  digestive  organs,  particularly  of  the  liver.  6.  Organic  dis- 
ease or  serious  functional  disturbance  of  the  kidney.  7.  Peculiar  forms  of 
food  and  drink,  the  infiuence  of  the  latter  seeming  to  be  especially  marked 
in  certain  localities  (?). 

(776) 


THE    UEINAET    DIATHESES.  777 


THE  UEINARY  DIATHESES. 


The  conditions  arising  from  these  various  influences  are  best  known  as 
diatheses^  the  most  important  forms  being  the  uric,  or  lithic;  the  oxalic, 
and  the  phosphatic. 

The  Ueic-Acid,  oe  Lithic,  Diathesis. — This  is  now  masquerading 
as  a  new  medical  fad,  "lithemia,"  an  omnibus  term  that  is  being  made  to 
cover — perhaps  justly — as  many  and  indefinable  conditions  as  does  "ma- 
laria." It  occurs  mainly  in  robust,  well-fed,  and  plethoric  individuals  who 
are  "high  livers,"  or  who,  in  plain  terms,  eat  too  much,  defecate  too  little, 
and  live  a  life  of  physical  inertia.  As  prime  factors  in  the  train  of  morbid 
conditions  the  terminus  of  which  is  lithemia,  these  subjects  often  have  irri- 
table dyspepsia,  sluggish  livers,  gout,  or  rheumatism.  Very  often,  too,  they 
are  the  victims  of  eczema  or  psoriasis.  Thin,  apparently  anemic,  and  neu- 
rotic persons  are  also  often  lithemic.  The  voided  urine  is  scanty,  high-col- 
ored, of  high  specific  gravity,  and,  on  cooling,  deposits  crystals  of  uric 
acid  and  urates  of  soda  or  ammonia  in  the  form  of  yellowish  or  red  sedi- 
ment, the  latter  color  predominating  whenever  the  deposit  is  largely  uric- 
acid  crystals,  and  the  former  when  amorphous  urates  are  in  excess.  The 
concretions  that  form  in  the  urinary  apparatus  in  this  diathesis  are  of  two 
kinds,  viz.:  uric  acid  and  the  urate  of  ammonia.  The  uric-acid  calculus  is 
usually  of  small  or  medium  size,  smooth,  of  oval  form  and  brownish  color. 
On  median  section  it  is  observed  to  be  laminated,  and  of  quite  hard  con- 
sistency. Calculi  of  ammonic  urate  are  quite  rare  and  are  usually  found 
in  children.  They  are  of  a  clayish  color  and  on  section  are  found  to  be  com- 
posed of  concentric  rings  of  the  urate. 

The  uric-acid  and  urate-of-ammonia  calculi  are  readily  differentiated 
by  dissolving  in  caustic  potash.  The  solution  of  the  latter  evolves  gaseous 
ammonia  in  quite  appreciable  amount. 

Treatment. — The  treatment  of  the  lithic  diathesis  is  of  a  general  char- 
acter, and  consists  chiefly  in  correcting  imperfect  digestion  and  malassimila- 
tion  and  improving  oxygenation  of  the  blood.  Liquors  of  all  kinds,  espe- 
cially sweet  wines  and  malt  liquors,  sweet-meats,  and  pastry  must  be  inter- 
dicted. The  saline  laxatives  and  abundant  quantities  of  alkaline  mineral 
waters,  such  as  the  Garrod  Spa,  with  an  occasional  blue  pill  are  very  essen- 
tial. Piperazin,  cystogen,  lithia,  and  colchicum  with  diuretics  are  beneficial 
in  most  cases.  Turkish  baths  should  be  taken  frequently,  and  the  skin 
briskly  rubbed  night  and  morning.  Abundant  exercise  will  prove  a  helpful 
and  necessary  factor  in  the  treatment. 

The  Oxalic-Acid  Diathesis. — This  manifests  itself  by  oxaluria,  or 
the  presence  of  the  characteristic  crystals  of  oxalate  of  lime  in  the  urine. 
Assimilation  is  usually  defective,  and  the  patient  is  generally  neurotic  or 
nervous  and  depressed  from  sexual  excesses  or  overwork.  Considerable  men- 
tal anxiety  is  apt  to  be  associated  with  the  other  conditions.     Dyspepsia, 


778  UEIXAET    CALCULUS. 

disturbed  sleep,  and  loss  of  sexual  power  are  frequent  symptoms.  The 
urine  is  generally  abundant  and  pale,  yet  highly  acid,  sometimes  causing 
smarting  in  its  passage.  It  is  probable  that  many  obscure  cases  of  pain  in 
the  back  are  due  to  irritation  of  the  kidneys  by  crystals  of  oxalate  of  lime 
or  uric  acid  in  the  secreted  urine.  There  is  no  sediment,  properly  speak- 
ing; yet  the  peculiar  octahedral  crystals  of  the  oxalate  of  lime  are  discern- 
ible under  the  microscope.  The  calculus  that  occurs  in  this  '"'oxaluric'' 
condition  is  of  small  or  moderate  size,  of  a  dark-brown  color,  and  presents 
a  rough,  tuberculated  surface,  which  peculiarity  gives  rise  to  the  appella- 
tion "mulberry  calculus." 

It  is  claimed  that  a  trace  of  free  oxalic  acid  exists  normally  in  the 
blood. 

Treatment. — The  treatment  of  oxaluria  or  oxalemia  is  chiefly  directed 
to  regulation  of  the  diet  and  the  relief  of  nervous  disturbances.  The  diet 
should  be  nourishuig,  but  light  and  unstimulating,  stimulants  being  inter- 
dicted altogether.  Tonics,  such  as  quinin.  strychnin,  iron,  and  the  mineral 
acids  are  essential.  The  dilute  nitromuriatic  acid  is  especially  beneficial, 
probably  because  the  condition  of  malassimilation  underlying  the  oxaluria 
is  dependent,  to  a  certain  degree  in  many  cases,  upon  perversion  of  the 
hepatic  functions.  Ehubarb  and  tomatoes  should  not  be  eaten  by  oxalurics, 
as  they  are  active  causes  of  oxalemia.  Ehubarb  is  especially  to  be  inter- 
dicted. 

The  Phosphatic  Diathesis. — This  occurs,  as  a  rule,  in  old  or  debil- 
itated individuals  or  those  whose  occupation  demands  great  mental  strain 
with  its  consequent  excessive  waste  of  nervous  tissue.  The  phosphatic  di- 
athesis is  occasionally  observed  in  children.  The  author  has  had  under  ob- 
servation for  some  years  a  young  girl  whose  urine  is  constantly  alkaline  and 
loaded  with  phosphates,  under  a  mixed  diet,  and  whose  teeth  have  under- 
gone a  most  extraordinary  cretaceous  transformation.  Whatever  the  nutri- 
tive perversion  underlying  this  case  may  be,  the  condition  is  relieved  in  a 
remarkable  manner  by  the  mineral  acids  and  a  diet  of  proteids.  In  such 
cases  the  mistake  is  often  made  of  administering  phosphates.  The  ab- 
surdity of  this  is  obvious.  The  deposits  and  calculi  that  form  in  this  di- 
athesis may  appear  in  the  form  either  of  the  ammonio-magnesian  or  triple 
phosphate,  phosphate  of  lime,  or  the  mixed  (earthy)  phosphates.  The 
triple  and  calcic  phosphates  appear  in  pale,  readily  decomposable  urine,  and 
are 'often  mixed  with  an  abundance  of  mucus.  The  mixed  phosphates  gen- 
erally appear  in  alkaline  urine  in  cases  of  cystitis,  paralysis  of  the  bladder, 
advanced  prostatic  disease,  or  stricture. 

Phosphatic  calculi  are  extremely  common,  as  might  be  inferred  from 
their  intimate  association  with  obstructive  diseases  of  the  genito-urinary 
tract.  The  most  frequent  variety  is  the  mixed,  or  "fusible,"'  calculus,  so 
called  because  of  the  readiness  with  which  it  melts  down  under  the  action 
of  heat.    This  form  is  friable,  of  laminated  structure,  and  earthy  or  chalky 


k 


VESICAL    CALCULUS.  779 

appearance.  The  ammonio-magnesian  calculus  is  rarer,  and  of  a  still  more 
chalky  appearance.  The  calcic-phosphate  calculus  is  the  rarest  of  the  phos- 
phatic  deposits  and  is  much  harder  than  the  other  yarieties  of  phosphatie 
stone. 

Treatment. — The  treatment  of  the  phosphatie  diathesis  should  consist 
mainly  of  the  administration  of  an  abundance  of  nitrogenized  food,  tonics, 
and  the  mineral  acids.  The  hygienic  management  is  of  the  utmost  impor- 
.tance.  ISTervous  strain  should  be  lessened  or  removed  if  possible,  and  plenty 
of  exercise  in  the  open  air,  short  of  fatigue,  advised.  The  mineral  acids  are 
sometimes  of  service  where  phosphaturia  is  due  to  some  local  disease,  but 
alkalies  in  combination  with  the  vegetable  acids  are  usually  preferable  in 
such  conditions. 

Eaee  Ueixaet  Deposits. — There  are  a  few  rare  deposits  that  may 
enter  into  the  composition  of  urinary  calculi.  The  most  important  of  these 
are  cystin;   xanthin,  or  xanthic  oxid:    and  carbonate  of  lime. 

The  various  urinary  solids  are  designated  by  different  terms  according 
as  they  appear  in  the  amorphous,  crystalline,  or  concrete  form.  "When 
amorphous  they  are  called  sediments,  when  crystalline  or  in  small  particles, 
gravel,  the  term  calculi  being  applied  when  they  occur  in  concrete  masses. 

VESICAL  CALCTTLUS. 

The  frequency  of  calculous  disease  attests  its  great  importance.  With 
our  improved  methods  of  early  diagnosis  and  operation,  however,  very  few 
persons  actually  die  of  stone.  The  proportion  of  deaths  from  calculus  in 
this  country  has  not  been  estimated,  so  far  as  the  author  is  aware.  Statis- 
tics show  that  in  England  calculus  causes  1  death  per  100,000  of  popula- 
tion, in  Scotland  1  in  50,000,  and  in  Ireland  1  in  200,000. 

Etiology. — The  causes  of  vesical  calculus  are  those  of  calculous  dis- 
ease in  general,  and  have  been  largely  outlined  in  the  consideration  of  the 
various  diatheses;  but  there  are  a  few  other  practical  points  requiring  at- 
tention. 

Heredity  is  a  very  important  factor  in  the  etiology  of  calculus.  The 
tendency  to  calculous  disease  in  some  families  is  very  striking.  Eace  seems 
to  have  its  influence,  the  negro  being  peculiarly  exempt.  The  Mongolian, 
Egyptian,  and  East  Indian  races  are,  however,  subject  to  it.  Sex  is  of 
great  importance,  calculi  being  met  with  twenty  times  more  frequently  in 
the  male  than  in  th^  female.  Ten  men  die  of  the  disease  to  one  woman. 
This  disparity  between  the  sexes  is  explained  by  the  difference  in  habits 
and  diet,  and  the  fact  that  the  female  urethra  is  so  short  and  capacious 
that  small  calculi  escape  with  the  urine,  instead  of  remaining  to  form 
nuclei  for  larger  concretions. 

Age  is  all  important,  the  two  extremes  of  life  being  especially  liable. 
According  to  the  greatest  living  authority.  Sir  Henry  Thompson,  young 
children  are  very  subject  to  the  disease;  thus,  in  1800  cases  of  stone  he  found 


780  UEINAKY    CALCULUS. 

over  500  children  under  the  age  of  five  years.  This  marked  predisposition 
of  children  is  peculiar,  especially  as  stone  often  occurs  in  apparently  healthy 
children.  There  is  a  marked  tendency  to  lithic  conditions  even  in  infants, 
and  this  cannot  alwaj^s  be  attributed  to  peculiarities  of  diet.  Many,  cases 
arise  before  a  mixed  diet  is  assumed. 

Stone  is  very  frequent  in  the  children  of  the  poorer  classes,  while  in- 
frequent in  those  of  the  well-to-do,  the  conditions  being  precisely  the  re- 
verse of  those  that  prevail  in  the  adult  under  the  same  circumstances.  Well- 
to-do  people  who  are  given  to  excessive  eating  and  liquor-drinking  without 
taking  the  proper  amount  of  exercise  are  prone,  when  well  along  in  years, 
to  develop  calculus.  The  extra  activity  of  the  habits  of  children,  and  the 
relatively  greater  activity  of  tissue-metabolism  prevalent  in  them,  tends, 
when  they  are  well  fed,  to  protect  them  from  calculous  disease.  In  the 
children  of  the  poorer  classes,  on  the  contrary,  bad  hygienic  surroundings, 
improper  and  insufficient  food,  with  consequent  malassimilation  and  pro- 
found trophoneurotic  disturbance,  predispose  to  calculus. 

In  a  general  way,  dyspepsia  and  faulty  assimilation  bear  an  important 
relation  to  stone  in  children.  When  children  are  fed  largely  upon  milk 
of  good  quality  they  are  not  liable  to  stone  to  any  degree,  providing  the 
digestion  be  normal. 

At  the  other  extreme  of  life,  or  above  middle  age,  the  frequency  of  cal- 
culus is  easily  explained.  It  is  at  this  time  that  gluttony,  intemperance, 
and  hereditary  gout  show  their  accumulative  effect.  It  is  at  this  time  also 
that  obstructive  diseases  of  the  urinary  apparatus,  particularly  stricture  and 
enlarged  prostate,  first  appear  or  at  least  manifest  their  full  effects.  For- 
eign bodies  in  the  bladder,  vesical  tumors,  or  other  vesical  disease,  and 
obstructive  diseases  of  the  urinary  tract — of  which  enlarged  prostate  is  the 
type — are  frequent  causes  of  vesical  calculus. 

Frequency  op  Vesical  Calculus.  —  The  frequency  of  vesical  cal- 
culus varies  considerably  in  different  localities  in  the  United  States.  Thus, 
in  the  Eastern  States  it  is  comparatively  rare,  while  it  is  more  common  in 
Ohio,  Tennessee,  and  Alabama,  and  especially  frequent  in  Kentucky.  It 
has  been  asserted  that  the  character  of  the  drinking-water  in  certain  locali- 
ties is  a  prominent  factor  in  the  etiology  of  calculus.  This,  however,  is 
probably  erroneous. 

As  Watson  has  pointed  out:— 

Any  pure  water,  like  distilled  Avater  for  example,  tends  to  increase  the  quantity 
of  urine,  to  cleanse  the  urinary  passages  of  mucus,  and  to  keep  the  urinary  salts  in 
solution.  To  this  extent,  therefore,  drinking-water  exercises  a  certain  influence  in  the 
prevention  of  stone  in  the  localities  in  which  such  water  is  found.^ 

Cold  climates  seem  to  favor  the  disease.    Other  things  being  equal,  the 


F.  Watson:    "American  Text-book  of  Genito-Ui'inary  and  Skin  Diseases.' 


STEUCTUKE  OF  CALCULI. 


781 


chief  causes  of  calculus  are  heredity,  excessive  ingestion  of  nitrogenized 
food,  intemperance,  dyspepsia,  gout,  foreign  bodies,  and  obstructive  urinary 
disease. 

Steuctuee  of  Calculi. — The  structure  and  form  of  calculi  vary  al- 
most as  much  as  their  chemic  composition.  Sometimes  they  are  homogene- 
ous in  structure,  but  most  often  they  present  on  section  a  uric-acid  nucleus 


Fig.  163. — Principal  varieties  of  urinary  calculi:  1,  Urate-of-ammonium  cal- 
culus -with  small  quantity  of  uric  acid  and  earthy  phosphates  in  its 
laminae.  2,  Uric-acid  calculus,  showing  internal  crystalline  and  external 
laminated  sti'ucture.  3,  Cystic-oxid  calculus.  4,  Alternating  calculus 
with  urate-of-ammonium  and  calcium-oxalate  nucleus.  Laminae  are  com- 
posed of  alternate  layers  of  calcium  oxalate,  uric  acid,  ammonium  urate, 
and  earthy  phosphates.  5,  Xanthic-oxid  calculus.  6,  Calcium-oxalate 
calculus,  sho^^■iIlg  mulberry  form.  7,  Calculus  of  triple  phosphates  with 
tobacco-pipe  nucleus. 


783  TEIXAEY    CALCULUS. 

surrounded  hy  layers  of  different  chemie  composition,  according  to  the  state 
of  the  bladder  and  chemie  characters  of  the  urine  at  the  time  of  deposition 
of  each  layer.  The  uric-acid  nucleus  is  usually  surrounded  by  strata  of 
lithates,  more  rarely  by  phosphatic  deposit.  In  many  instances,  however, 
the  inner  and  older  strata  consist  of  lithates,  and  the  more  recent  ones  of 
phosphates.  Next  in  frequency  comes  the  nucleus  of  calcium  oxalate,  or 
perhaps  the  clear  mulberry  calculus  with  little  or  no  deposit  upon  it.  Most 
infrequently  we  meet  with  pure  phosphatic  calculi.  There  may  be  only 
one,  or,  less  frequently,  several  nuclei,  these  being  sometimes  round  and 
comparatively  smooth,  and  in  other  instances  very  irregular.  The  body  of 
the  stone  surrounding  the  mulberry  nucleus  is  most  often  calcium  oxalate, 
but  is  sometimes  composed  of  phosphatic  lamina?.^ 

Pure  calcium  oxalate,  uric  acid,  and  the  urates  are  deposited  as  a  result 


Fig.  164. — Calculus  formed  around  a  hair-pin^  the  ends  of  which 
are  visible.     (After  Poulet.) 

of  constitutional  conditions,  while  the  phosphatic  laminae  that  so  often  form 
upon  them  are  due  to  the  vesical  irritation  produced  by  the  nuclei.  Any 
foreign  body  will  act  upon  the  bladder  in  the  same  manner,  causing  irrita- 
tion and  inflammation,  this  being  followed  by  infection,  with  consequent 
urinary  decomposition  and  phosphatic  deposit.  The  author  recalls  a  curi- 
ous case  operated  upon  at  the  IsTew  York  Charity  Hospital: — 

Case. — A  large  calculus  was  removed  from  the  bladder,  and  upon  section  its 
nucleus  was  found  to  be  a  portion  of  the  seam  of  the  crotch  of  a  pair  of  pants.  The 
patient  was  standing  upon  a  chair  some  years  before,  when  it  broke  and  he  fell  upon 
the  fragments.     One  of  the  splintered  rungs  of  the  chair  was  driven  into  his  anus, 


^  Of  184  stones  removed  by  Sir  Henry  Thompson  by  lithotrity,  122  were  com- 
posed of  uric  acid  and  urates ;  16  of  mixed  composition;  40  phosphatic;  1  pure  phos- 
phate of  lime;    4  oxalate  of  lime;    and  1  cystic  oxid. 


LOCATION,    WEIGHT,    AND   NUMBER    OF    CALCULI. 


783 


through  the  rectal  walls  and  into  the  bladder  at  the  trigone,  carrying  with  it  the 
piece  of  cloth  that  afterward  formed  a  nucleus  for  stone. 

Almost  every  conceivable  substance  has  been  found  as  the  nuclei  of 
calculi.  Pieces  of  slate-pencil,  hair-pins,  broken  catheters,  etc.,  have  been 
found  in  the  center  of  vesical  calculi,  having  been  introduced  into  the  blad- 
der as  a  means  of  gratifying  perverted  sexuality.  The  sediments  of  the 
urine  crystallize  upon  these  foreign  bodies  very  much  as  does  a  solution 
of  sugar  or  alum  upon  a  thread.  In  a  general  way,  nuclei  are  usually  of 
renal,  and  calculous  laminae  of  vesical,  origin.  Sometimes,  however,  as  al- 
ready stated,  nuclei  come  from  without;  again,  they  are  formed  in  loco  by 
mucus  or  muco-pus,  around  a  gout  of  which  laminated  deposit  occurs. 

Location  of  Calculi. — Under  favoring  conditions  calculus  may  form 
in  any  part  of  the  genito-urinary  tract.  It  may  form  at  any  point  of  ob- 
struction as  a  result  of  urinary  decomposition  and  precipitation  of  urinary 
salts,  or  at  any  point  of  lodgment  of  a  small  nucleus  coming  down  from 
the  kidney.    From  a  strictly  surgical  stand-poi;it,  calculi  are  of  the  greatest 


Fig.  165. — Handle  of  a  tooth-brush,  covered  with  calcareous  deposit,  found 
in  a  young  girl's  bladder.      (After  Poulet.) 


importance  when  located  in  the  urinary  bladder.  It  is  here  that  they  are 
most  often  detected,  and  it  is  in  this  region,  therefore,  that  operations  for 
their  removal  are  most  frequently  performed. 

XuMBER  OF  Calculi. — The  number  of  calculi  that  may  be  found  in 
the  bladder  in  different  cases  varies  greatly.  As  a  rule,  but  one  stone  is 
found,  but  cases  have  been  reported  in  which  a  large  number  of  calculi  of 
various  forms  and  sizes  were  removed.  Physick  reported  a  case  that  is  now 
familiar  to  every  surgeon,  in  which  he  removed  nearly  a  thousand  small 
stones  varying  from  the  size  of  the  head  of  a  pin  to  that  of  a  pea.  Several 
calculi  sometimes  become  matted  together  by  adhesive  muco-pus,  and  fused 
into  one  by  subsequent  phosphatic  deposit.  More  often,  however,  they  re- 
main free,  and  produce  facets  upon  each  other  by  attrition  of  their  surfaces, 
although  they  may  remain  smooth  and  round. 

Size  and  Weight  of  Calculi. — The  size  of  calculi  is  very  variable, 
ranging  from  the  size  of  a  pin's  head  to  indefinite  dimensions.  McGregor, 
of  New  York,  reported  one  of  51  ounces'  weight  and  16  Vg  inches  circum- 
ference.   Cline  reported  one  of  44  ounces.    A  weight  of  6  pounds  has  been 


784 


UEIXAET    CALCULUS. 


said  to  have  been  attained  in  one  case,  but  the  authenticity  of  this  is  doubt- 
ful. Nearly  all  of  the  enormous  stones  that  have  been  reported  have  been 
removed  post-mortem,  their  presence  having  in  many  cases  escaped  atten- 
tion during  life.  With  the  revival  of  the  suprapubic  operation  many  cases 
formerly  considered  inoperable  will  be  brought  to  a  successful  issue  and 
there  will  be  fewer  cases  neglected  because  of  the  excessive  size  of  the 
stone.  The  weight  of  ordinary  calculi  varies  from  a  few  drams  to  several 
ounces. 

CoNSiSTEXCY  AXD  FoE^i  OF  Calculi. — The  consistenc}^,  hardness,  and 
form  of  calculi  are  very  important  considerations  to  the  surgeon.  Their 
consistency  and  hardness  vary  with  their  composition.  The  oxalate  of  lime 
or  mulberry  calculus  is  the  hardest,  the  uric  acid  or  urates  next,  and  the 
phosphatic  the  softest.    The  external  laminae  of  calculi  are  very  often  quite 


Fig.  166.^ — Ovoid  calculus  formed  around  a  bean.     (After  Poulet.) 


soft  and  friable,  while  the  nuclei  are  very  hard  and  dense.  Calculi  are 
usually  round  or  oval,  the  mulberry-stone,  however,  the  chief  exception  to 
this  rule,  being  globular  and  rough  in  most  instances. 

Sharp  and  irregular  fragments  are  occasionally  produced  by  fracture  of 
a  large  stone.  The  causes  of  this  spontaneous  fracture  are  obscure,  but  it 
has  been  supposed  to  be  due  either  to  the  contractions  of  an  hypertrophied 
and  powerful  bladder,  or  to  concussion  against  another  stone.  Ord  has 
claimed  this  to  be  due  to  the  presence  of  "colloid  material"  in  the  composi- 
tion of  the  stone,  the  swelling  of  which  produces  its  fracture. 

In  the  majority  of  instances  calculi  lie  free  in  the  cavity  of  the  blad- 
der, quite  exceptionally  they  are  fixed  and  encysted,  or  lodged  in  some  of 
the  sacculi  met  with  in  diseased  bladders.  Occasionally  they  are  impacted 
in  the  mouth  of  the  ureter,  behind  a  diseased  prostate,  or  imbedded  in  a 
morbid  growth. 


MOEBID   ANATOMY   AND    SYMPTOMS    OF    VESICAL    CALCULrS. 


785 


MoEBiD  Anatomy.  —  The  morbid  anatomy  of  yesical  calculus  is,  in 
general,  the  same  as  that  of  organic  stricture  of  the  urethra  and  other  ob- 
structive diseases  of  the  bladder,  and  has  been  outlined  in  detail  in  the 
chapters  on  stricture.  To  recapitulate  briefly,  the  changes  consist  of  chronic 
inflammation  and  infection  of  the  bladder,  and  in  extreme  cases  the  ure- 
ters and  renal  pelves.  The  walls  of  the  bladder  are  hypertrophied,  perhaps 
sacculated,  and  the  mucous  membrane  is  covered  with  phosphatic  deposit, 
mucus,  and  muco-pus.  The  ureters  and  pelves  of  the  kidney  are  dilated 
in  extreme  cases,  and  even  in  comparatively  recent  cases  the  renal  pelves 


Fig.  167. — Cluster-calculus  formed  around  a  head  of  wheat. 
(After  Poulet.) 

are  affected  by  pyelitis.     Surgical  nephritis,  pyelonephritis,  pyonephrosis, 
or  perinephritie  abscess  and  perhaps  renal  stone  may  be  present. 

Symptoms. — The  symptoms  of  vesical  calculus  are  variable,  their  char- 
acter and  severity  depending  upon  the  dimensions,  form,  and  multiplicity 
of  the  stones  and  the  constitution  of  the  patient.  Obviously  a  free  calculus 
will  give  rise  to  more  definite  symptoms  than  the  encysted  form;  indeed, 
the  symptoms  of  the  latter  are  often  very  obscure.  In  a  general  way,  the 
severity  of  the  symptoms  depend  chiefly  upon  the  size  of  the  stone,  ex- 
ceptions to  this  being  occasionally  noted,  in  which  a  very  large  stone  gives 
rise  to  slight  symptoms,  while  a  small  stone  causes  intense  suffering.    Angu- 


786  UEIXAEY    CALCULUS. 

lar  and  roiigli  calculi  are  more  painful  than  ovoid;,  smooth  ones,  because 
of  the  higher  degree  of  inflammation  they  induce. 

All  of  the  symptoms  of  stone  are  dependent  upon  direct  mechanic 
irritation  and  reflex  spasm.  Pain,  frequent  and  painful  micturition,  occa- 
sional sudden  stopisages  of  the  stream  during  micturition,  hematuria — espe- 
cially at  the  end  of  the  act  of  urination — and  morbid  conditions  of  the 
voided  urine  comprise,  in  a  general  way,  the  principal  symptoms. 

The  pain  is  referred  chiefly  to  the  hypogastrium  and  perineum,  but 
often  radiates  along  the  groins  and  inner  aspect  of  the  thighs.  A  peculiar 
cutting  or  lancinating  pain  along  the  under  surface  of  the  penis  and  re- 
ferred to  the  end  of  the  glans,  is  a  frequent  s3'mptom.  This  may  be  the 
first  thing  noticeable,  especially  in  children,  Avho  announce  it  by  pulling 
at  the  penis  in  their  efforts  to  relieve  the  pain.  Care  must  be  exercised  in 
estimating  the  value  of  this  symptom  in  adults.  The  author  has  observed 
a  number  of  cases  of  neuralgic  pain  of  this  sort  due  to  prostatic  and  vesical 
irritation  from  other  causes  than  stone,  or  following  chronic  urethral  dis- 
ease. The  pain  of  calculus  is  aggravated  by  movement,  especially  that  of 
a  jolting  kind,  as  in  riding  over  rough  streets.  Pain  is  most  marked  at  the 
end  of  micturition,   when  the   calculus   is   suddenly  forced   against,   and 


Fig.   168. — Thompson's  searcher  for  stone. 

grasped  by,  the  sensitive  vesical  neck.  If  an  exacerbation  of  cystitis  be 
present,  the  suffering  is  intense. 

When  the  kidneys  are  secondarily  affected  albumin  is  present  and  may 
be  detected  in  the  decanted  or  filtered  urine.  In  advanced  cases  the  urine 
nearly  always  contains  the  products  of  cystitis,  viz. :  phosphates,  mucus,  and 
muco-pus,  and  in  some  cases  more  or  less  blood;  rarely,  indeed,  is  the  urine 
perfectly  clear,  and  then  only  in  the  early  history  of  the  case. 

A  very  significant  symptom  is  sudden  stoppage  of  the  flow  of  urine 
during  micturition  due  to  sudden  impaction  of  the  stone  against  the  ves- 
ical neck.  On  assuming  the  recumbent  posture,  the  patient  is  again  able 
to  void  the  urine.  Among  the  more  exceptional  symptoms,  prolapsus  ani 
and  hemorrhoids  from  straining  during  micturition;  priapism,  especially 
in  children;  and  edema  of  the  prepuce  are  sometimes  noted.  In  encysted 
calculus  all  of  the  discomfort  incidental  to  a  movable  stone  is  usually  ab- 
sent, with  the  exception  of  frequent  micturition  and  pain  due  to  vesical 
irritation. 

Diagnosis.  —  The  diagnosis  of  vesical  calculus  cannot  be  positively 
made  without  instrumental  exploration  of  the  bladder.  Por  this  purpose 
the  "searcher"  devised  by  Thompson  is  the  best  instrument,  although  an 


DIAGNOSIS    OF    VESICAL    CALCULUS. 


787 


ordinary  steel  sound  is  often  satisfactory.     The  searcher  possesses  the  ad- 
vantages of  lightness,  slenderness,  and  a  short  beak,  and  is  perforated  like 
a  catheter  for  the  purpose  of  injecting  or  withdrawing  fluid  as  required. 
The  bladder  should  contain  three  or  four  ounces  of  urine  or  warm 


Fig.  169.-^Sounding  for  stone  above  pubes.     (After  Erichsen.) 

water,  in  order  that  it  shall  be  moderately  distended,  and  thus  prevented 
from  grasping  the  sound  or  concealing  the  stone  in  a  fold  of  the  mucous 
membrane.  The  patient  may  be  anesthetized  by  chloroform  if  the  stone  is 
not  found  readily.  In  most  cases,  however,  the  injection  of  a  4-per-cent. 
solution  of  cocain  suffices.    Care  should  be  taken  to  thoroughly  anesthetize 


Fig.  170.; — Sounding  for  stone  in  the  Ms-fond.     (After  Erichsen.) 

the  prostatic  urethra.  The  patient  being  placed  upon  his  back  with  the 
hips  elevated,  the  knees  moderately  flexed  upon  the  thighs  and  the  thighs 
upon  the  abdomen,  the  instrument  is  warmed  and  lubricated  and  passed 
into  the  bladder  far  enough  to  reach  the  posterior  wall   of  the  viscus. 


7S8 


UEIXAEY    CALCrLrS. 


It  should  now  be  rotated  froni  side  to  side  in  sueli  a  manner  that  its  curve 
and  point  sweep  over  the  sides  and  base  of  the  organ,  and  then  withdrawn 
a  short  distance  with  a  repetition  of  the  rotation.  By  these  maneuvers  of 
giadual  rotation  and  withdrawal  the  entire  floor  and  walls  of  the  bladder 
are  thoroughly  explored.  The  sound  should  be  removed  as  soon  as  its  eon- 
caTity  reaches  the  vesical  neck.  If,  however,  enlarged  prostate  exists,  the 
instrument  should  be  reintroduced  as  far  as  the  center  of  the  bladder.  Its 
point  should  then  be  turned  downward  and  slowly  withdrawn  until  it  is 
obstructed  by  the  prostate,  the  handle  being  depressed  weU  down  between 
the  thighs.  By  this  procedure  a  stone  in  the  las-fond  posterior  to  the  pros- 
tate will  not  often  escape  detection.  The  surgeon  is  not  justified,  however, 
in  pronouncing  upon  the  character  of  the  case  when  rational  sjTnptoms  of 
stone  are  present  yet  no  stone  is  found  at  the  first  exploration,  until  he  has 
had  one  or  two  additional  opportunities  to  search  the  bladder. 


lilg.  171. — Sounding  for  encysted  calculus.     (After  Eric-hsen.) 


"When  stone  is  strongly  suspected  and  is  not  readily  found,  it  may  some- 
times be  discovered  by  requesting  the  patient  to  stand  erect,  and  then  allow- 
ing the  -arine  to  flow  through  the  instrument  or  searcher.  As  the  last  few 
drops  of  the  urine  are  exiDcUed,  the  stone  is  likely  to  come  in  contact  with 
the  searcher  with  a  decided  click  and  impulse.  This  clicking  sound  is  the 
pathognomonic  indication  of  stone  and  may  often  be  heard  at  a  consider- 
able distance. 

Information  to  &e  Gained  hy  Exploration. — There  are  several  points 
that  may  be  determined  by  exploration,  viz.:  the  consistency,  size,  and 
munber  of  stones,  and  sometimes  the  fact  of  encystment.  By  the  accentua- 
tion of  the  click  and  the  peculiar  feel  imparted  to  the  hand,  we  can  usu- 
aHv  make  a  fair  estimate  of  the  hardness  of  calculi.  If  a  small  lithotrit« 
be  used,  multiplicity  of  the  stones  can  be  determined  quite  readily,  by 
grasping  one  of  the  stones  in  the  Jaws  of  the  instrument  and  striking  it 


DIAGNOSIS    OF   VESICAL   CALdTLTTS.  T89 

against  the  otiiers.  In  the  same  way  we  can  form  an  estimate  of  thdr 
size  and  shape.  When  a  stone  remains  constantly  in  the  same  position, 
and  cannot  he  moved  ahout  hy  the  exploring  instrument  or  in  changing 
the  position  of  the  patient,  and  the  heak  of  the  instrument  cannot  he  passed 
around  it,  it  is  safe  to  conclude  that  the  stone  is  encysted:  i.e.,  contained 
in  a  saeeulus.  Very  often  the  bulging  of  the  vesical  walls  abont  sach  a 
calculus  can  he  felt  with  the  instrument. 

There  are  several  sources  of  fallacy  to  be  taken  into  consideration  in 
the  diagnosis  of  stone.  In  some  cases  of  contracted  fasciculated  bladder  the 
mucous  membrane  becomes  so  thickly  incmsted  with  phosphatie  deposit 
that  a  quite  sharp  click  may  be  eKcited  by  the  instrument.  As  a  rule, 
however,  the  sensation  and  sound  are  of  a  rough,  grating  character.  In 
children  the  walls  of  the  bladder  are  so  thin  that  the  searcher  will  often 
occasion  a  distinct  click  by  striking  against  the  pelvic  bones. 

Vesical  calculus  in  the  female  presents  the  same  symptoms  and  results 
as  in  the  male,  but  the  stone  is  more  easily  detected  by  exploration.  A  short, 
straight  instrument  should  be  used  and  the  floor  of  the  bladder  manipulated 
through  the  roof  of  the  vagina  by  the  fingers  of  the  free  hand.  In  this  way 
the  stone  may  be  caught  between  the  fingers  and  the  instrument,  or  at 
least  brought  sharply  in  contact  with  it. 

Dangers  of  Exploration. — ^In  exploring  for  stone  the  possible  seri- 
ousness of  the  operation  must  be  didy  considered.  When  the  bladder  is 
acutely  inflamed,  the  inflammation  may  be  so  seriously  enhanced  by  in- 
strumentation that  sloughing  of  the  mucosa  occurs,  with  a  resultant  typhoid 
state  and  death.  Death  may  also  result  immediately  from  shock,  or  sec- 
ondarily from  some  form  of  urine-fever  or  septemia.  Shock  is  especially 
apt  to  occur  in  old  and  debilitated  persons  of  a  nervous  temperament. 
Uremia  from  suppression  of  the  renal  function  by  reflex  inhibition  of  the 
kidney  is  the  most  frequent  form  of  urine-fever  affecting  these  cases.  The 
systems  of  old  persons  with  large  calculi  being  usually  empoisoned  by  long- 
continued  absorption  of  morbific  material  from  the  diseased  surfaces, — 
chronic  urine-fever, — ^it  is  obvious  that  but  little  additional  toxemia  is  re- 
quired to  induce  a  fatal  result.  In  order  to  avoid  these  untoward  effects  of 
instrumentation  certain  precautions  are  essential.  Xo  case  of  long  stand- 
ing should  be  explored  without  first  ascertaining  the  condition  of  the  kid- 
neys, as  near  as  may  be,  by  urinalysis.  Examinations  must  not  be  made 
during  acute  exacerbations  of  cystitis.  In  all  cases  exploration  should  be 
very  gentle  and  not  too  prolonged.  It  should  be  remembered  that  in  most 
cases  the  bladder  is  septic.  The  slightest  traumatism  of  the  vesical  mncosa, 
therefore,  may  lead  to  septic  absorption  and  possibly  serious  results.  The 
chief  danger  of  exploration,  however,  in  certain  cases  lies  in  the  general 
anesthesia  necessary  far  exploration.  For  this  reason,  it  is  often  well  to 
be  prepared  for  immediate  operation  in  case  stone  is  found.  Eepetition 
of  the  anesthesia  with  its  attendant  dansrers  mav  thus  be  avoided.     The 


790  UEIXAKY    CALCULUS. 

prophylaxis  of  possible  injury  from  instrumentation  is  precisely  the  same 
as  advised  for  '"urine-fever."' 

Pkogxosis. — Vesical  calculus  is  invariably  fatal,  sooner  or  later,  unless 
the  course  of  the  disease  is  interruj)ted  by  operation  or  death  from  inter- 
current disease.  Death  is  due  to  exhaustion  from  pain,  nervous  irritation, 
disturbed  sleep,  and  chronic  urine-fever, — urinar}^  toxemia, — in  conjunc- 
tion with  interference  "vrith  the  function  of  the  kidneys.  Under  proper 
treatment  the  disease  is  curable  in  a  large  majority  of  cases.  Eecurrence 
is  frequent  because  of  the  underlying  diathesis. 

Treatmext. — The  treatment  of  vesical  calculus  is  almost  exclusively 
surgical.  When  a  stone  has  been  detected  in  the  bladder  there  is  practically 
no  hope  of  relief  short  of  an  operation  for  its  removal.  Lithontriptics,  or 
stone-solvents,  were  at  one  time  quite  popular.  Experience  and  observa- 
tioii  have  shown,  however,  that  they  are  valueless,  save  perhaps  in  prevent- 
ing the  formation  of  stone  or  limiting  to  a  certain  extent  increase  in  size 
of  a  stone  already  formed.  It  is  possible  that  small  concretions  may  be  dis- 
solved by  these  remedies;  but  after  a  stone  has  entered  the  bladder  and 
manifested  its  presence  by  symptoms  it  is  a  waste  of  time  to  dally  with 
solvent  treatment.  Xearly  all  of  the  non-surgical  remedies  recommended 
for  stone  have  been  of  an  alkaline  character.  Chevalier  being  the  first  to 
call  especial  attention  to  the  value  of  alkalies  in  calculous  disease.  The 
Vichy  Springs  have  been  highly  indorsed  in  calculus,  and  are  of  some  value 
in  the  lithie  diathesis,  not  only  by  virtue  of  their  alkalinity,  but  also  from 
the  fact  that  in  the  large  quantities  usually  taken  they  render  the  urine 
less  concentrated. 

As  an  illustration  of  the  implicit  faith  in  lithontriptics  possessed  by 
the  public  in  former  days,  the  celebrated  nostrum  of  Joanna  Stephens  is 
most  striking.  This  remedy  was  supposed  to  be  so  infallible  that  in  1739 
a  reward  of  £5000  was  paid  the  inventor  by  the  English  government.  It 
was  subsequently  discovered  that  the  nostrum  was  composed  of  burnt  egg- 
shells and  snails  in  combination  with  soap. 

Eoberts,  the  famous  English  authority  upon  renal  diseases,  is  a  firm 
believer  'in  the  solvent  treatment  of  calculus.  He  believes,  however,  that  it 
is  only  useful  in  small  calculi  composed  of  uric  acid  or  the  urates.  The 
treatment  consists  in  neutralization — not  alkalinization — of  the  urine  by 
the  citrate  or  acetate  of  potassium.^ 

Solvent  remedies  have  been  injected  into  the  bladder.  Sir  Benjamin 
Brodie  indorsed  dilute  nitric  acid  in  a  strength  of  m.  iij  to  the  ounce  of 
water  in  phosphatic  calculi.  Doubtless  this  treatment  is  beneficial  where 
the  phosphatic  deposit  is  not  too  dense,  or  as  a  prophylactic  of  stone  in  ad- 
vanced bladder  or  prostatic  disease.  In  large  stones  its  use  is  worse  than 
follv. 


^  First  published  in  1SG5:    Medico-Chiriirgical  Transactions. 


TKEATMENT    OF   VESICAL    CALCULUS.  791 

Attempts  have  been  made  to  cure  calculi  by  electrolysis,  but  with  in- 
different success.  Bryant  has  recommended  a  simple  procedure  that  some- 
times succeeds  in  removing  small  calculi  as  follows: — 

Patients  who  are  prone  to  the  passage  of  renal  calculi  into  the  bladder,"  and  to 
the  formation  of  lithie  acid  or  other  gravel,  should  be  directed  once  a  day  when  the 
full  bladder  is  about  to  discharge  its  contents,  to  arrest  the  flow  of  urine  by  holding 
the  penis,  and  then  suddenly  to  allow  the  stream  to  flow.  In  this  way  the  water, 
passing  with  a  rush,  carries  with  it  any  small  stone  or  tand  which  may  be  resting  in 
the  bladder.     Old  men  should  do  this  upon  their  hands  and  knees. 

It  is  unfortunate  that  the  various  non-surgical  methods  of  treatment 
of  vesical  calculus  are  so  seldom  successful.  Operation  is  necessary  sooner 
or  later  in  nearly  all  cases:  a  fact  that  is  something  of  a  reproach  to  scien- 
tific medicine. 

SELECTION    OF    OPEEATIOISr   FOE    STONE. 

The  selection  of  cases  for  the  several  operations  for  stone  is  a  matter 
of  vital  importance.  In  children  lithotomy  is  the  most  generally  applicable, 
because  of  its  safety  and  the  small  size  of  the  bladder  and  urethra,  which 
renders  lithotrity  much  more  difficult  than  in  the  adult.  Lithotomy  should 
be  performed  as  soon  as  practicable  after  the  diagnosis  of  stone  has  been 
determined.  The  dangers  of  calculus  depend  upon  the  duration  of  the  dis- 
ease and  the  size  of  the  concretion.  The  dangers  of  fatal  renal  or  bladder 
complications  and  the  fatality  of  operations  are  directly  dependent  upon 
these  two  circumstances;  hence  the  earlier  the  operation  is  performed,  the 
better.  The  fatality  of  lithotomy  in  children  is  quite  small,  and  it  is  prob- 
able that  one  death  in  thirty  operations  is  a  very  liberal  estimate  of  the  mor- 
tality-rate in  patients  under  puberty  operated  by  competent  surgeons.  This 
will  be  alluded  to  again  more  specifically. 

The  mortality  of  litholapaxy  varies  with  the  age  of  the  subjects,  the 
rate  being  about  3.5  in  children,  5.3  per  cent,  in  adults,  and  8  per  cent,  in 
old  men.  The  improvement  in  mortality-rate  over  the  old  operation  of 
lithotrity  is  marked.  Thompson  lost  twenty-nine  cases  out  of  seventy-eight 
adults  operated  by  lithotrity.  Jn  fairly  good  conditioned  adults  with  a 
moderate  amount  of  bladder  and  renal  complications,  and  a  stone  of  an 
inch  and  a  half  or  less  in  diameter,  lithotrity  is  the  preferable  operation. 
The  operation  is  to  be  taken  into  consideration  as  the  operation  of  election 
in  all  cases  in  adults.  The  hardness  of  the  stone  may  compel  the  surgeon 
to  resort  to  lithotomy,  but  this  can  only  be  determined  by  trial  with  a 
lithotrite.  The  suprapubic  operation  is  so  safe  in  favorable  cases  in  adults 
that  it  is  preferable  to  litholapaxy  unless  the  surgeon  is  expert  in  its  per- 
formance. The  mortality  of  litholapaxy  depends  greatly  on  the  care  with 
which  cases  are  selected.  Thompson  lost  about  one  case  in  thirteen  be- 
fore he  realized  the  necessity  of  a  more  careful  selection  of  cases  as  regards 
the  size  of  the  stone,  condition  of  the  bladder,  etc.     Under  favorable  cir- 


IS«t 


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iwaamftfssied  lis  |Bmjj*iH.  :>9iCHK  it  k  a  «at£te  of  mne  to  dalbf  vifk 

sid^^^i  oei!2»aBiL  X«Kr.T  £_  ^f  liie  »aii.ai!wieai  lemedi^  leeoiiaBeiided 
Sbr  SLKaaE*  loaw  litesBa  «€  am  aBlfcalliwip  dsaiactieE.  Ciievalacr  bes^g  tlie  fiist  to 
call  e^Bccial  atseaaitasn  w  tlae  ¥a!ne  «3!f  aHalaes  m  edcnloos  dssease.  Hie 
Tadsf"  %EiB^  ba^ne  bees  lu^jili-  indassiBd  m.  ealenlos,  arad  are  of  some  Tifaie 
IB  &e  latAiBe  difldbesK.  boc  obIt  hr  Timae  of  tls€ar  aOEaliaurr.  bnt  ateo  from 
ijbe  &es  ^m.  ib  ib^'  laise  ■qpaaifiTirw^  sfstallhr  lalseB  liafr  i^eBder  tihe  mine 

wfSfr  ®6B6EBQafi£OL 

Af  aa  iIS^saai5«iB  <^  tiae  inpSscii  saiili  im  Ihltoffitriiiiticg  poeBeseed  br 

.  'liSae  im  jDacBter  dav^  dae  eeieiiaated  BOESi^m  of  Joanna  St^besE  is 

^•:>f;:  .snriMBg.    TTiiBg  uttKE'  -    :  posed  to  be  so  Jin^lHhi**  Ibat  in  1739 

a  Acwjiad  «£  iSid@0  vae  paic  :..  :  ._ '^otor  br  tlae  T&wgtipli  gui<anmeaii.  It 
vas  SBlKEi^pBEBtiv'  dB9Ci0V¥9<Hi  flaai  tbe  bo^svib  vas  eoispoeBd  of  bamt  egg- 
i^JbtfflAf  and  qngB^  in  esmSbimssssei  ■     ~x 

Soiiies^  alfie  Shbbo^  TSmgi^,-  _  _ ._ .  zitr  iqpm  lemal  djasaaFg^  is  a  &91 
beBeva- m  ^ht  ssix&es,  neaaB^m  of  falfffllBf-  He  bdie^es.  boweva;,  Ibat  it 
is  <^a&^  iei^3i£  iaa  ssaM  eaSe^M  ccnspGiaEd  <c»f  'one  aod  lor  tbe  matps  Tlie 
SBsaEani^s  &s^sss^  in  nemnalizsEsois — 3>c»r  ^lla^TroTriaTMTm — «f  t^  ■sstsse  by 

leaaec  '     -  _^r  i^add^c    Sir  Senjamin 

dL.-i.  __.-_ „  i'_- -__-:_  sf  HL.  iij  to  tJie  OTznce  of 

■BSSKff  iffi  ;piBS^SBa&ie  eakalL  l>!Ka4)d^  t^t^  ^rr-fsmmpmt  is  beiitf-da]  -s-iierB 

^ifiS'  ffeffl^isiie  d^i     ■  r_-^,  i^-  as  a  f:              '_e  of  stiinsie  in  ad- 


Jiiast  fftJRiftina  ioa  lSi»:    UfaganB-miM  —igV.jl  IJo^aactifSiK. 


TEZ-iTirFATT   or   VZilCAJl   CajLCCjIUS.  T&l 

Attempts  KaTc  been  made  to  enre  calenH  by  electrQlyss,  bxtt  wife,  in- 
different success.  Brrant  has  reG-omnLettded  a  sfrnple  proceiiire  that  SQine- 
tLoies  sncc-eeds  in  rem.0Ting  gmaTT  caLcnK  as  foRown: — 

Patients  wiio  are  prone  to  tfie  passage  of  renal  caleali  into  tKe  IsIaddeTj"  and  ta 
the  formation  of  KtMe  add  or  otKer  graveL  stould  be  directed  once  a  day  wien.  tie 
fall  bladder  is  abont  to  discharge  its  contents,  to  arrest  the  &yw  of  nrfne  by  holdrng 
the  penis,  and  then  anddenly  to  aHo-sr  the  stream,  to  liow-.  In  this  way  the  witter, 
passing  with  a  rash,  carries  with  it  any  gmaTT  stone  or  sand  which  may  be  restrng  in. 
the  bladder.     Old  men  should  do  this  upon  their  hands  and  knees. 

It  is  Tmfominate  diat  th.e  Tarions  non-snigieaL  methods  of  treatnieiit 
of  TesicaL  c-aLcnlTis  are  so  seldom  snc-c-essfnL  Operatfon  is  necessacy  sooner 
or  later  in  nearlv  all  cases:  a  fact  that  is  som.etiiing  of  a  reproach,  to  scien- 
tific medicine. 

5EJLECTI05"   OF   0PEBAII05"  ZQS   aTO^TE. 

The  selection  of  c-ases  for  the  seTexal  operatLons  for  stoite  Is  a  mafccer 
of  Tital  importance.  In  children  Kthotomr  is  the  most  generalLy  applicahlff, 
because  of  its  safety  and  the  small  size  of  the  bladder  and  nrethra.  which, 
renders  Hthotrity  mnch  m.ore  ditn.ctilt  than  in  the  adnlt.  Lithotomy  shotild 
be  performed  as  soon  as  practic-able  after  the  diagnosis  of  stone  has  been 
determined.  The  dangers  of  c-alcnlns  depend  upon  the  dttration  of  the  dis- 
ease and  the  size  of  the  concretion.  The  dangers  of  &tal  renal  or  bladder 
complications  and  the  fatality  of  operations  are  directly  dependent  npon 
these  two-  eircnmstances:  henc-e  the  earlier  the  operation  is  performed,  the 
better.  The  fatality  of  lithotomy  in  children  is  quite  smaTT^  and  it  is  prtib- 
able  that  one  death  in  thirty  operations  is  a  very  liberal  estimate  of  the  m.or- 
tality-rate  in  patients  nnder  pttberty  operated  by  eom^petent  surgeons.  TTis 
vrilL  be  allnded  to  again  more  specifically. 

The  mortality  of  Ktholapaxy  yaries  with  the  age  of  the  sobjeets.  the 
rate  being  about  3.5  in  children.  5.3  per  cent,  in  adnlts.  and  S  per  cent,  in 
old  men.  The  improvement  in  mortality-rate  over  the  old  operatioiL  of 
Kthotrity  is  marked.  Thompson  lost  tweitty-nine  eases  ont  of  seventy-eight 
adults  operated  by  Hthotrity.  _Li  fisidy  good  eeaadrfcioiLed  adults  with 
moderate  amount  of  bladder  and  renal  CQmplic-ations.  and  a  stone  of  in 
inch  and  a  half  or  less  in  diameter.  lithotrity  is  the  preferable  operation. 
The  operation  is  to  be  taken  into  eonsLderation.  as  the  QpsatiiKi  «xl  eleetion 
in  all  cases  in  adults.  The  hardness  of  the  stone  may  compel  the  surgeon, 
to  resort  to  lithotomy^  bnt  this  can  only  be  determined  by  trial  wEch  a 
Hthotrite.  The  suprapubic  operation  is  so  safe  in  favorable  eases  m.  adul-fe 
that  it  is  preferable  to  Ktholapaxy  unless  the  surgeon  is  expert  in.  its  per- 
formance. The  mortality  of  litholapaxy  depends  greatly  on  the  care  with. 
which  cases  are  selected-  Thompson.  lost  abotEfc  one  ease  in  thirteen  oe- 
f ore  he  realized  the  necessity  of  a  more  careful  selection  of  cases  as  regards 
the  size  of  the  stone,  condition  of  the  bladder,  etc.    Under  favorable  cir- 


793  UEIXAEY    CALCULUS. 

cumstances  there  is  no  more  danger  in  litholapaxy  than  in  any  case  of  in- 
strumental interference  with  the  urethra  and  bladder,  and  when  we  con- 
sider the  occasional  deaths  from  simple  catheterization  a  certain  degree  of 
mortality  in  litholapaxy  is  by  no  means  surprising  nor  an  argument  against 
the  operation.  ,  When  severe  bladder  complications  or  indubitable  renal  dis- 
ease exist,  litholapaxy  does  not  offer  so  many  advantages  as  suprapubic 
lithotomy;  hence  the  latter  is  to  be  preferred.  When  for  any  reason  it  is 
found  difficult  to  introduce  and  manipulate  the  instruments  necessary  for 
litholapaxy,  the  cutting  operation  must  be  resorted  to.  This  is  likely  to 
be  the  case  in  some  cases  of  prostatic  disease,  bar  at  the  vesical  neck,  strict- 
ure, and  in  extremely  nervous  and  cowardly  patients.  Under  all  these  con- 
ditions the  author  acknowledges  a  preference  for  suprapubic  section.  In  the 
rare  cases  of  calculus  in  which  no  operation  whatever  is  practicable,  life 
may  at  least  be  greatly  prolonged  and  made  more  comfortable. 

To  epitomize  briefly:  1.  Lithotomy  seems  still  to  be  the  standard  oper- 
ation in  children,  litholapaxy  being  indicated  only  exceptionally.  2.  Lithol- 
apaxy is  to  be  the  rule  in  adults,  the  cutting  operation  being  j)erformed 
only  when  the  crushing  operation  is  impracticable.  3.  Stones  above  an  inch 
and  a  half  in  diameter,  very  hard  stones,  stones  with  foreign  bodies  as  nuclei, 
most  cases  of  multiple  calculi,  cases  with  complicating  stricture,  and  severe 
bladder,  prostatic,  or  renal  disease  require  lithotomy,  preferably  the  supra- 
pubic operation.  Litholapaxy  gives  the  best  results  in  old  men  in  whom 
the  stone  is  accessible  and  the  bladder  and  kidneys  in  fair  condition.  Amer- 
ican surgeons  are  perhaps  inclined  to  attack  larger  stones  by  litholapaxy 
than  are  considered  by  European  surgeons  to  be  removable  by  crushing. 
Keyes  concludes  upon  this  point  as  follows: — 

1.  When  stone  complicates  enlarged  prostate,  if  the  condition  of  the  latter  be 
such  that  were  the  stone  absent  no  operation  would  be  called  for,  then  the  whole 
question  is  to  be  solved  by  deciding  whether  the  obstructive  quality  of  pi'ostatic  en- 
largement, the  size  of  the  bus,  the  depth  of  the  Ms-fond,  the  irritability  of  the  pro- 
static urethra,  and  its  resentment  of  instrumental  interference — whether  any  of  these 
factors  be  sufficiently  accentuated  to  make  litholapaxy  impossible,  or  to  make  it 
possible  only  at  the  expense  of  leaving  the  patient  (as  to  his  subjective  symptoms) 
worse  than  before. 

If  such  conditions  do  obtain,  then  the  stone  should  be  removed  by  the  knife. 

2.  In  short,  the  main  matter  is  one  of  diagnosis  by  the  searcher,  the  cystoscope, 
rectal  touch,  and  the  tentative  testing  of  the  prostatic  urethra  with  instruments. 

3.  The  size  or  position  of  the  stone  is  not  a  factor,  except  in  the  case  of  encysted 
stone,  or  one  too  large  for  the  lithotrite  to  grasp,  or  in  the  case  of  a  foreign  body. 
The  smallness  alone  of  the  stone  is  relatively  an  argument  against  litholapaxy,  since 
the  symptoms  in  such  a  condition  must  be  ascribed  rather  to  the  prostate  than  to 
the  foreign  body. 

4.  If  lithotomy  be  performed,  the  suprapubic  route  should  be  selected,  since  this 
opens  the  door  to  more  perfect  work,  and  allows  the  surgeon  to  remove  obstructions, 
such  as  third  lobe,  interstitial  growths,  outstanding  horse-collar  enlargement,  bar,  and 
to  lower  the  vesical  end  of  the  urethral  floor,  thus  accomplishing  all  that  could  be 


LITHOTRITY    AND    LITHOLAPAXY.  793 

done   by   a   more   extensive    prostatectomy,    without   very    seriously    increasing    the 
operative  risk. 

5.  Finally,  here,  as  elsewhere  in  surgery,  the  only  safe,  practical  guide  is  surgical 
judgment,  based  upon  diagnosis,  guided  by  experience/ 

LiTHOTRiTY  AND  LiTHOLAPAXY. — History  of  Litlioirity . — It  is  prob- 
able that  lithotrity  is  a  very  ancient  operation.  According  to  Ultzmann;, 
it  was  performed  as  early  as  the  ninth  century.  To  what  degree  of  per- 
fection the  operation  attained,  history  does  not  show.  So  far  as  the  re- 
searches of  those  who  have  given  the  history  of  the  operation  especial 
attention  have  gone,  it  would  be  inferred  that  the  procedure  and  the  instru- 
ments for  its  performance  were  very  crude.  The  operation  evidently  fell 
into  desuetude,  for  it  was  not  seriously  proposed  in  modern  times  until 
the  early  part  of  the  present  century.  In  1813  Gruithuisen,  of  Salzburg, 
Bavaria,  proposed  an  operation  for  crushing  stone  in  the  bladder  by  means 
of  a  loop  of  wire  passed  through  a  metal  tube  into  the  bladder;  the  stone 
was  to  be  caught  in  the  loop  of  wire,  drawn  tightly  against  the  vesical  end 
of  the  tube,  and  crushed  by  means  of  a  sharp-pointed  stylet  passed  through 
the  tube  and  made  to  impinge  forcibly  against  the  stone,  which  was  thereby 
split  in  two.  The  operation  of  splitting  was  to  be  repeated  until  the  frag- 
ments were  sufficiently  small  to  be  evacuated  per  urethram.  It  is  hardly 
necessary  to  say  that  the  performance  of  such  an  operation  would  demand 
superhuman  skill  and  ingenuity.  The  first  experiments  in  crushing  stones 
in  the  human  body  were  performed  upon  the  cadaver  by  Fournier,  of  Paris. 
The  first' systematic  work  on  the  subject  was  published  in  1818,  one  year 
later  than  Fournier's  experiments,  by  the  brilliant  young  surgeon,  Civiale. 
The  first  lithotrite  was  invented  by  Civiale.  Elderton,  a  Scotch  surgeon, 
perfected  a  method  of  lithotrity  and  published  a  description  of  his  opera- 
tion in  1819.  Elderton  has  frequently  been  styled  the  father  of  lithotrity, 
but,  as  will  be  seen,  he  was  merely  following  in  the  footsteps  of  Fournier  and 
Civiale.  Fournier  should  really  have  the  credit  that  has  been  given  Elder- 
ton.  Civiale,  however,  was  the  first  surgeon  to  crush  a  stone  in  the  living 
subject.  This  operation  was  performed  in  1824.  Since  that  time  the  oper- 
ation has  been  greatly  improved  by  Civiale  himself,  Heurteloup,  Sir  William 
Ferguson,  Dittel,  Nelaton,  and  Sir  Henry  Thompson.  No  great  improve- 
ment was  made  in  the  operation  of  lithotrity  by  any  subsequent  operator 
until  the  late  Prof.  H.  J.  Bigelow,  of  Boston,  perfected  his  operation  of 
rapid  lithotrity,  or  litholapaxy. 

The  greater  popularity-  of  the  crushing  operation  in  our  own,  as  com- 
pared with  foreign  countries,  is  mainly  due  to  the  untiring  efforts  of  Bige- 
low, who  w^as  one  of  the  first  to  advocate  and  the  first  to  systematize  and 
perfect  the  technic  of  complete  removal  of  the  stone  at  one  sitting,  instead 
of  by  successive  operations  and  irrigations.     By  his  modified  lithotrity — or 


^  Annals  of  Surgery,  May,  1898. 


794  UEIXAEY    CALCULUS. 

litholapaxy — Bigelow  demonstrated  not  only  the  tolerance  of  the  bladder 
for  prolonged  manipulations  within  its  cavity,  but  the  feasibility  of  intro- 
ducing practically  straight  tubes  into  the  bladder  for  the  purpose  of  wash- 
ing out  the  calculous  detritus  produced  by  crushing. 

Prior  to  Bigelow's  demonstrations  the  foundation  for  litholapaxy  was 
laid  by  Fessenden  Otis,  who  showed  the  tolerance  of  the  urethra  for  instru- 
ments of  large  size.  Great  credit  is  due  Bigelow,  but  it  should  be  remem- 
bered that  the  indefatigable  labors  of  Otis  paved  the  way  for  litholapaxy. 

Lithotrity,  like  many  other  excellent  procedures  of  a  surgical  char- 
acter, has  suffered  greatly  at  the  hands  of  its  overenthusiastic  friends.  The 
sudden  transition  from  the  necessity  of  a  cutting  operation  to  the  possibil- 
ity of  a  bloodless  method  of  dealing  with  calculi  turned  the  heads,  not  only 
of  the  surgeons  who  accepted  it  with  undue  confidence  in  its  safety  and 
simplicit}^,  but  of  the  patients  as  well.  Carelessness,  on  the  one  hand,  and 
oversanguine  expectations  on  the  other,  necessarily  led  to  disappointment, 
and  it  was  not  long  before  the  profession  began  to  realize  that  lithotrity 
was  not  invariably  applicable,  was  often  fatal,  and,  moreover,  required  con- 
siderable skill  and  Judgment  in  its  performance.  As  a  corollary,  the  neces- 
sity for  a  judicious  selection  of  cases  was  soon  recognized. 

The  operation  of  litholapaxy,  or  rapid  lithotrity  with  evacuation  of 
fragments,  has  completely  supplanted  the  ordinary  operation  of  lithotrity. 
The  advantages  of  removing  the  detritus  at  once,  and  thus  completing  the 
operation  at  one  seance  instead  of  allowing  the  more  or  less  pulverized  frag- 
ments to  remain  in  the  bladder  are  sufficiently  plain.  In  the  old  operation 
a  number  of  sittings  were  required,  all  equally  dangerous  and  painful,  such 
fragments  as  had  been  pulverized  to  a  sufficient  degree  of  fineness  being  al- 
lowed to  escape  at  will  with  the  urine  after  each  crushing,  large  fragments 
being  reserved  for  future  crushings.  Later  on  in  the  history  of  the  opera- 
tion some  of  the  detritus  was  washed  out  at  each  sitting.  When  the  sur- 
gical world  learned  from  Bigelow  the  extreme  degree  of  tolerance  of  opera- 
tive manipulations  possessed  by  the  bladder,  and  from  Otis  the  possibility 
of  using  tubes  of  considerable  caliber  in  evacuating  the  fragments  after 
crushing  the  stone,  the  more  primitive  operation  of  interrupted  crushings 
went  to  the  dead-lumber  room. 

Techxic  of  Litholapaxy. — -The  patient  should  be  prepared  for  at 
least  a  week  prior  to  the  operation,  by  alkalies,  diluents,  rest,  and  a  milk 
diet;  in  short,  such  measures  as  have  already  been  suggested  in  connection 
vrith  the  subject  of  genito-urinary  hygiene.  Urinary  antiseptics  should  be 
given,  eucah'ptus  and  salol  being  the  best.  If  the  bladder  be  irritable  and 
the  urine  ammoniacal,  it  should  be  washed  out  twice  daily  until  it  will  hold 
from  four  to  six  ounces  of  urine  and  has  become  accustomed  to  instru- 
mental interference.  Aperients  and  an  enema  should  be  given  before  the 
operation. 

The  instruments  necessary  for  litholapaxy  are  two  or  more  lithotrites, 


LITHOTEITY   AND    LITHOLAPAXY. 


795 


evacuating  tubes  of  several  sizes,  and  an  evacuator.  Bigelow  devised  special 
patterns  of  all  these  appliances,  the  modifications  of  which  are  the  best  now 
in  use.  Clover's  evacuating  apparatus  or  its  modifications  may,  however, 
be  used  if  preferred.  It  is  well  to  have  at  least  two  lithotrites  of  different 
sizes,  with  perhaps  an  extra  one  to  provide  for  accidental  breakage  of  an 
instrument. 

Operation. — When  the  bladder  is  infected  it  should  be  irrigated  thor- 
oughly before  the  operation  is  begun,  and  distended  by  a  warm  antiseptic 


Fig.  172. — Modified  Bigelow  lithotrite. 

solution:  bichlorid  of  mercury,  1  to  10,000;  or  boric  acid.  If  the  urine  is 
healthy,  from  4  to  6  ounces  may  be  allowed  to  remain  in  the  bladder  in 
lieu  of  the  antiseptic  solution.  Some  surgeons  prefer  to  use  the  solution 
in  all  cases,  believing  that  the  bladder  tolerates  the  antiseptic  fluid  better 
than  urine.  The  correctness  of  this  view  is  doubtful;  if,  however,  cocain 
be  used,  the  injection  of  water  greatly  facilitates  the  operation,  and  renders 
it  practically  painless.  In  some  of  the  author's  cases  most  satisfactory 
results  have  been  obtained  by  the  use  of  1-per-cent.  solution  of  cocain. 


Fig.  173. — Clover's  evacuating  apparatus  and  tubes. 


in  the  urethra  and  a  V2-per-cent.  solution  in  the  bladder.  The  cocain 
should  be  dissolved  in  1-per-cent.  solution  of  carbolic  acid.  Antipyrin, 
10  per  cent.,  adds  to  the  anesthetic  effect  of  the  solution,  and  is  perfectly 
harmless.  It  is  not  necessary  to  give  a  general  anesthetic  in  a  certain 
proportion  of  cases.  Where  it  can  be  avoided  it  is  better  to  do  so,  as  the 
sensations  of  the  patient  are  a  valuable  guide  in  the  operation.  If  the  pa- 
tient is  very  nervous,  the  urethra  extremely  tender,  the  prostate  enlarged, 
or  the  bladder  irritable,  general  anesthesia  may  be  advisable;   but  even  in 


796 


UKIXAEY    CALCULUS. 


such  cases  the  use  of  cocain  will  often  obviate  the  necessity  of  general 
anesthesia.     Where  it  is  unavoidable,  chloroform  is  best. 

The  patient  should  be  placed  upon  a  narrow  operating-table  covered 
by  a  quilt  or  hair-mattress  of  firm  texture,  with  his  knees  slightly  flexed  and 
separated,  and  a  cushion  or  pillow  under  his  hips,  care  being  taken  not  to 
expose  any  more  of  the  body  than  is  absolutely  necessary,  chill  being  very 
dangerous  in  these  cases. 

The  lithotrite  should  next  be  warmed  and  lubricated  and  introduced 
into  the  bladder,  being  allowed  to  pass  into  the  organ  by  its  own  weight. 


Fig.  174. — English  method  of  seizing  the  stone  in  lithotrity. 
(After  Brodie.) 

Great  care  is  necessary  in  the  operation  lest  the  mucous  membranes  be 
abraded,  thus  affording  atria  for  the  absorption  of  toxic  materials  with  re- 
sultant septic  or  urine-fever. 

The  instrument  having  entered  the  bladder,  its  convexity  should  be 
pressed  downward  toAvard  the  rectum,  and  the  blades  of  the  lithotrite  sep- 
arated slowly  and  carefully,  thus  permitting  the  stone  to  fall  between  them, 
as  it  will  do  in  by  far  the  majority  of  cases.  Should  it  not  do  so  readily, 
the  hips  may  be  elev,ated,  and  failing  in  this  they  may  be  depressed,  in 
the  hope  of  catching  the  stone.    Before  each  of  these  maneuvers  the  blades 


LITHOTEITY   AXD    LITHOLAPAXY.  797 

of  the  instrument  should  be  opened,  else  the  male  blade  may  push  away  the 
stone  as  it  rolls  into  the  desired  position.  If  the  prostate  is  not  greatly 
enlarged  and  the  las-fond  is  not  deep  enough  to  conceal  the  stone,  these 
procedures  are  usually  successful  in  grasping  it.  If  not,  an  attempt  should 
be  made  to  pick  up  the  stone  by  rotating  the  beak  of  the  lithotrite  from 
side  to  side  successively,  the  angle  of  deflection  being  about  45°.  Finally, 
the  beak  of  the  instrument  may  be  turned  directly  downward  behind  the 
prostate,  thus  searching  the  las-fond.  The  essential  points  in  these  manipu- 
lations are  (1)  to  avoid  bringing  the  instrument  in  contact  with  the  ves- 
ical walls  so  far  as  possible,  and  (2)  to  open  the  jaws  of  the  lithotrite 
before  changing  its  j)osition  from  side  to  side. 

So  far  as  the  main  principles  of  the  technic  of  stone-crushing  are  con- 
cerned, little  or  nothing  of  importance  has  been  added  since  the  systematic 
descriptions  of  it  published  by  Heurteloup  and  Civiale,  save  certain  minor 
modifications  instituted  by  Sir  Benjamin  Brodie  and  Sir  Henry  Thompson. 
As  described  by  the  latter,  the  "English  method"  is  as  follows: — 

The  patient  lying  on  his  back,  the  handle  of  the  lithotrite  is  elevated,  thus 
bringing  the  convex  part  of  its  curved  extremity  in  contact  with  the  posterior  surface 
of  the  bladder.  The  lithotrite  is  then  to  be  opened  to  a  greater  or  less  extent,  accord- 
ing to  the  probable  size  of  the  calculus,  the  fixed  blade  being  at  the  same  time  pressed 
gently  downward  in  the  direction  of  the  rectum.  The  object  of  this  maneuver  is  to 
bring  the  lithotrite  below  the  level  of  the  other  parts  of  the  bladder  so  that  the 
calculus  may  fall  between  the  jaws  of  its  own  weight,  and  is  generally  successful.  If 
it  should  fail,  the  lithotrite,  without  being  moved  from  its  situation,  may  be  gently 
struck  on  one  side  of  the  handle  or  on  its  anterior  part;  the  slight  coneussioii  thus 
commimicated  to  the  bladder  will  probably  be  sufficient  to  dislodge  the  calculus,  and 
bring  it  within  the  grasp  of  the  instrument.  If  it  should  be  otherwise,  the  instrument, 
being  closed,  may  be  very  gently  and  cautiously  turned  to  one  side  or  the  other,  so 
that  the  curved  extremity  of  it  may  make  an  angle  of  25°  or  even  30°  with  the 
vertical  line  of  the  body,  then  opened  and  pressed  in  the  direction  of  the  rectum  in 
the  manner  already  described. 

When  the  prostate  gland  is  much  enlarged  there  is  sometimes  difficulty  in  seizing 
the  calculus,  arising  either  from  its  lying  under  that  part  of  the  gland  which  projects 
into  the  bladder  or  from  the  impediment  which  it  offers  to  the  elevation  of  the  handle 
of  the  instrument.  For  such  cases  the  operating-table  invented  by  Heurteloup,  which 
enables  the  patient's  shoulders  to  be  suddenly  lowered,  is  very  convenient.  The  cal- 
culus is  then  seized,  not  in  that  part  of  the  bladder  which  adjoins  the  rectum,  but  in 
the  fundus,  this  being  rendered  the  lowest  point  by  the  elevation  of  the  pelvis. 

In  the  classic  operation  of  Civiale  the  principle  followed  is  the  reverse 
of  the  foregoing: — 

By  the  position  of  the  patient,  the  center  of  the  bladder  and  the  space  beneath 
it  are  selected  as  the  area  of  operation;  no  depression  of  the  lithotrite  is  made; 
contact  between  the  walls  of  the  bladder  and  the  instrument  is,  as  much  as  possible, 
avoided.  The  instrument  is  applied  to  the  stone  in  the  situation  in  which  it  naturally 
falls,  and  the  operator  carefully  avoids  moving  it.  Movements  of  concussion,  how- 
ever slight,  are  apt  to  produce  serious  injury.  The  instrument,  having  entered  the 
bladder,  glides  smoothly  down  the  trigone,  which  in  the  normal  living  viscus  is  an 


798 


UKIKAEY    CALCULUS. 


inclined  plane.  In  many  instances  the  stone  is  touched  by  the  lithotrite  in  passing, 
and  the  slightest  lateral  movement  of  the  beak  shows  on  which  side  it  lies.  In  this 
event  the  operator  should  be  careful  not  to  disturb  it,  but  should  incline  the  beak 
slightly  away  from  the  stone  and  pass  the  instrument  gently  onward  to  the  posterior 
vesical  wall,  while  slowly  opening  its  jaws.  It  should  be  remembered  that  so  long 
as  the  blades  are  close  to  the  vesical  neck  they  cannot  be  opened  without  pain  or 
traumatism.  The  widely-opened  lithotrite  should  be  inclined  toward  the  stone  and 
slowly  closed.  The  stone  is  almost  certainly  seized.  If  no  stone  is  felt  on  entering 
the  bladder  the  surgeon  should  simply  withdraw  the  male  blade  an  inch  or  more  in 
the  median  line,  incline  the  blades  to  the  right  side  about  45°,  and  then  close  them 
without  otherwise  disturbing  the  angle  or  central  position  of  the  shaft.  It  will  be 
seen  that  in  almost  all  positions  the  stone  is  seized  sidewise.     If  no  stone  is  felt,  the 


Fig.  175. — French  method  of  seizing  the  stone  in  lithotrity, 
(After  Civiale.) 


blades  should  be  opened,  turned  to  the  left,  and  again  closed  in  a  similar  manner. 
The  blades  are  always  to  be  opened  before  they  are  turned.  If  the  turn  is  first  made 
and  the  blades  subsequently  opened,  the  male  blade,  as  it  is  withdrawn,  will  prob- 
ably move  the  stone  away.  If,  however,  the  blades  are  inclined  while  open,  the  stone 
will  quite  likely  be  seized.  The  stone  very  rarely  eludes  the  maneuvers  thus  far 
described.  Should  it  do  so,  however,  the  handle  of  the  lithotrite  should  be  depressed 
half  an  inch  or  so,  thus  raising  the  blades  very  slightly  from  the  floor  of  the  bladder. 
They  should  now  be  turned  horizontally  to  the  left.  If  this  maneuver  is  not  success- 
ful, the  blades  should  be  gently  turned  to  the  right  horizontal  position  and  closed. 

As  Thompson  points  out,  the  five  positions  of  the  blades  of  the  litho- 
trite embraced  in  the  foregoing  description  of  the  teehnic  of  lithotrity — 
viz.:    the  vertical,  right  and  left  inclined,  and  right  and  left  horizontal — 


LITHOTEITY   AND   LITHOLAPAXY.  799 

constitute  a  thorough  exploration  of  the  cavity  of  the  bladder,  and  enable 
the  surgeon  to  find  with  almost  absolute  certainty  any  stone  of  moderate 
or  large  size,  providing  the  conformation  of  the  bladder  be  normal.  Thomp- 
son especially  enjoins  the  surgeon  to  avoid  communicating  any  jerk  or  con- 
ciission  either  to  the  instrument  or  bladder.  It  is  only  necessary  in  the 
various  movements  outlined  to  barely  touch  the  walls  of  the  bladder  with 
the  lithotrite.  There  should  at  least  be  at  no  time  sufficient  roughness  of 
manipulation  to  excite  any  especial  degree  of  pain  or  produce  vesical  con- 
traction. When  the  prostate  is  sufficiently  enlarged  to  alter  the  form  of  the 
vesical  floor,  and  especially  to  change  the  conformation  of  the  true  vesical 
neck — i.e.,  the  prostatic  urethra — it  may  be  necessary  to  reverse  the  posi- 
tion of  the  lithotrite-blades  in  such  a  manner  that  they  point  downward 
toward  the  trigone.  In  this  manner  a  concealed  calculus,  a  very  small  stone 
or  a  fragment,  may  often  be  picked  up,  although  it  has  eluded  the  grasp  of 
the  instrument  in  every  other  maneuver  and  position.  In  searching  for 
small  calculi  or  fragments  Thompson  recommends  a  lithotrite  with  short 
blades,  which,  he  claims,  and  with  reason,  can  be  more  readily  reversed 
than  those  of  a  larger  instrument.  The  technic  of  picking  up  fragments 
and  small  or  concealed  stones  from  the  las-fond  is  described  by  him  essen- 
tially as  follows: — 

The  handle  of  the  lithotrite  should  be  depressed  another  inch  or  so  between  the 
patient's  thighs  so  that  the  axis  of  the  instrument,  instead  of  being  directed  obliquely 
a  little  upward,  is  in  a  horizontal  position,  or  even  a  little  below  it.  The  blades, 
which  are  supposed  to  have  been  already  brought  to  a  horizontal  position,  are  turned 
to  the  right  in  such  a  manner  as  to  point  obliquely  toward  the  vesical  floor,  which 
should  be  very  lightly  touched  by  them.  No  pressure  should  be  made  on  this  part 
of  the  bladder,  and  it  is  easily  avoided  by  depressing  the  handle  of  the  lithotrite.  The 
blades  during  this  maneuver  should  be  open  until  they  have  been  turned  to  the 
proper  degree,  and  then  they  should  be  closed.  They  should  now  be  reopened  and 
turned  back — i.e.,  upward  and  to  the  left— and  again  closed.  Finally  they  may  be 
brought  around  to  the  reversed  vertical  position,  with  the  beak  pointing  directly 
downward  and  the  floor  of  the  viscus  lightly  swept.  This  last  maneuver  requires 
considerable  depression  of  the  handle,  and  is  only  necessary  in  picking  up  small  frag- 
ments with  a  short-bladed  instrument.  When  the  prostate  is  considerably  enlarged, 
necessitating  search  for  a  calculus  or  fragments  behind  it,  the  position  of  the  beak 
of  the  lithotrite  is  reversed  Avithout  depressing  the  handle.  These  maneuvers  should 
be  executed  at  or  beyond  the  center  of  the  vesical  floor — the  proper  area  for  oper- 
ating. There  should  be  no  hurry,  no  rapid  movements,  nor  any  manipulation  what- 
soever characterized  by  jerk  or  concussion.  If  the  bladder  be  fairly  healthy,  the 
various  manipulations  described  should  not  be  attended  with  any  particular  amount 
of  pain. 

The  operator's  eye  should  be  so  familiar  with  the  scale  marked  on  the  sliding 
rod  of  the  lithotrite  that  he  knows  at  a  glance  the  exact  interval  between  the  blades 
in  the  bladder.  It  is  essential  while  manipulating  the  lithotrite  to  maintain  its 
axis,  so  far  as  possible,  always  in  the  same  direction.  The  blades  only  are  to  be 
moved;  the  shaft  should  occupy  the  same  inclination  unless  when  necessary  to  alter 
it  for  some  specific  purpose.  In  screwing  home  the  small  blade  the  operator  is  very 
apt  to  move  the  lithotrite  also  at  each  turn  of  the  screw,  unless  apprised   of  the 


800  URINAEY    CALCULUS. 

care  necessary  to  avoid  it.  All  lateral  movements,  all  vibration  and  concussion  neees- 
saiily  react  on  the  neck  of  the  bladder  and  prostatic  urethra,  where  the  instrument 
is  most  closely  embraced  and  its  mobility  most  limited.  To  that  part  of  the  lithotrite 
which  occupies  the  anterior  portion  of  the  urethra  much  freedom  of  lateral  move- 
ment is  permitted,  and  in  the  bladder  the  instrument  is  also  free,  although  in  less 
degree;  but  the  axis,  or  fixed  point,  as  regards  lateral  movement,  is  at  the  vesical 
neck,  which  is  also  the  most  sensitive  part  of  the  entire  canal.  The  aim  of  the 
operator  should  therefore  be  to  produce  in  this  situation  no  motion  of  the  lithotrite 
whatever,  except  that  on  its  own  axis.  Few  details  of  the  operation  require  more 
patience  for  its  mastery  than  this. 

Thompson  gives  several  original  and  very  valuable  practical  hints  re- 
garding the  location  and  method  of  seizure  of  the  calculus.     He  says: — 

The  larger  the  stone,  the  more  likely  it  is  to  be  found  near  the  vesical  neck 
when  the  patient  is  in  the  ordinary  recumbent  position.  A  small  stone  is  usually 
found  at  the  back  of  the  trigone.  The  position  of  the  large  stone  requires  a  special 
method,  and  it  will  be  found  almost  invariably  successful.  The  lithotrite  should  not 
be  pushed  onward  to  the  bottom  of  the  cavity  as  soon  as  it  enters  the  bladder. 
First  let  the  blades  be  inclined  away  from  the  side  on  which  the  stone  is  felt,  then 
push  on  the  female  blade  only,  as  far  as  it  will  go,  maintaining  the  male  blade  at 
the  neck  of  the  bladder.  It  is  now  only  necessary  to  incline  the  beak  toward  the 
stone,  and  it  will  almost  certainly  be  seized  at  once.  If  the  operator  commences 
by  pushing  on  the  whole  instrument  and  then  withdraws  the  male  blade  according  to 
the  ordinary  custom,  the  blade  is  infallibly  drawn  against  the  large  stone,  fails  to 
catch  it,  and  presses  it  back  against  the  neck  of  the  bladder,  producing  pain,  irritation, 
and  perhaps  bleeding. 

In  both  the  French  and  English  methods  of  seizing  the  calculus  the 
principal  point  is  the  extreme  gentleness  required  to  avoid  injury  to  the 
delicate  structures  about  the  prostate  and  vesical  neck,  for  in  direct  pro- 
portion as  this  is  avoided  will  be  the  success  of  the  operation.  In  the  Eng- 
lish method,  as  will  be  observed,  an  attempt  is  made  to  keep  the  female 
blade  in  one  position,  all  necessary  movements  in  grasping  the  stone  being 
made  so  far  as  possible  by  withdrawing  or  closing  the  male  blade.  If  the 
handle  of  the  lithotrite  be  elevated  and  the  point  thus  depressed,  the  male 
blade  may  be  moved  in  and  out  without  bruising  the  vesical  neck,  and  a 
good-sized  stone  may  thus  be  crushed  without  producing  severe  pain  or 
vesical  irritation. 

After  having  been  grasped  in  the  jaws  of  the  lithotrite,  the  stone  is  to 
be  crushed  by  turning  the  screw  slowly  and  steadily  until  the  stone  is  felt 
to  crumble  and  the  jaws  of  the  instrument  are  observed  to  be  closed  or 
quite  near  together — according  to  the  thoroughness  of  the  crushing.  The 
screw  must  be  turned  firmly,  but  slowly,  else  fragments  may  fly  about,  or 
the  stone  slip  and  do  injury  to  the  vesical  walls.  The  size  of  the  stone 
when  grasped,  and  the  degree  of  approximation  of  the  blades  of  the  litho- 
trite after  the  crushing,  may  be  measured  by  the  scale  upon  the  shaft  of  the 
instrument. 

It  is  at  this  point  that  the  difference  between  lithotrity  and  litholapaxy 


LITHOTRITY   AND    LITHOLAPAXY.  801 

begins.  In  the  former  operation  the  surgeon  makes  a  second  or  third  crush- 
ing of  the  larger  fragments  and  then  leaves  the  operation  for  another  sitting, 
either  trusting  to  the  flow  of  urine  during  micturition  to  bring  away  the 
detritus  or,  if  he  be  more  modern,  washing  it  away  with  an  evacuator  and 
tube.  In  the  latter  method  the  surgeon  proceeds  to  complete  the  operation 
by  crushing  every  fragment  large  enough  to  be  grasped  by  the  jaws  of  the 
lithotrite,  and  finally  evacuating  the  debris  completely  by  Bigelow's  evacu- 
ator and  tubes.  Time  is  scarcely  an  object  in  this  operation,  as  a  sitting 
of  several  hours'  duration  is  generally  well  tolerated.  The  time  which  may 
be  safely  occupied  depends  upon  the  expertness  and  technic  of  the  operator 
and  the  condition  of  the  patient's  kidneys  and  bladder. 

On  withdrawing  the  lithotrite  care  should  be  taken  that  no  fragments 
are  caught  in  its  jaws,  and  that  the  male  blade  is  screwed  tightly  home. 
It  has  been  recommended  to  elevate  the  blades  of  the  instrument  by  de- 
pressing its  handle,  open  them  and  tap  smartly  upon  the  end  of  the  handle, 
thus  freeing  any  particles  of  stone  that  may  be  adherent  to  the  blades. 

In  the  perfected  operation  of  litholapaxy,  if  skillfully  performed,  frag- 
ments and  no  danger  of  impaction  of  fragments  in  some  portion  of  the 
traction;  hence  there  is  no  danger  of  injury  to  the  urethra  by  sharp  frag- 
ments, and  no  danger  of  impaction  of  fragments  in  some  portion  of  the 
canal  to  give  serious  after-trouble  to  both  surgeon  and  patient.  The  ad- 
vantages of  immediate  removal  as  compared  with  leaving  until  a  future 
operation  sharp  fragments  that  cause  more  severe  irritation  than  did  the 
stone  before  the  crushing  are  sufficiently  obvious. 

If  the  fragments  of  calculus  have  been  crushed  with  sufficient  thor- 
oughness, the  evacuation  of  debris  is  usually  a  very  simple  procedure.  In 
the  performance  of  this  part  of  the  operation  as  large  a  tube  should  be  used 
as  it  is  practicable  to  introduce.  Any  obstructions  that  may  exist  in  the 
urethra  should  be  removed  by  incision.  The  meatus  will  very  frequently 
be  found  contracted  to  an  extent  sufficient  to  obstruct  the  passage  of  the 
tube.  Where  it  is  practicable  to  introduce  the  lithotrite  without  incising 
the  meatus,  it  is  well  to  reserve  the  incision  until  the  introduction  of  the 
evacuating  tube.  A  straight  and,  where  it  is  practicable  to  introduce  it, 
a  comparatively  short  tube  should  be  used.  The  tubes  in  general  use  are 
longer  than  necessary  excepting  in  such  cases  as  present  aberrant  conforma- 
tion of  the  prostatic  urethra  and  vesical  neck.  The  shorter  the  tube,  the 
greater  the  facility  of  washing  out  the  fragments.  In  the  pumping  process 
involved  in  the  evacuation  of  the  debris,  Watson  advises  the  following 
maneuver : — 

When  there  is  much  debris  it  is  well  to  commence  pumping  with  the  point  of 
the  tube  held,  a  little  above  the  floor  of  the  bladder.  During  this  earlier  part  of 
the  operation  there  should  be  no  interval  between  the  compression  and  expansion 
of  the  bulb.  The  object  at  this  time  is  to  set  the  fragments  whirling,  and  to  catch 
them  while  they  are  suspended.     If  the  end  of  the  tube  is  buried  too  deeply  in  the 


803 


UKIXAET    CALCULUS. 


detritus,  it  is  apt  to  be  clogged  at  the   outset,   and   evacuation   thereby   hindered. 

Later,  when  the  fragments  are  few,  the  tube  is  carried  to  the  floor  of  the  bladder, 
and  a  few  moments  should  elajDse  after  pressing  the  bulb  to 
give  the  fragments  time  to  settle  into  the  depression  about 
the  end  of  the  tube  before  the  expansion  which  is  to  suck 
them  into  it.  "\Mien  any  particular  aspiration  brings  frag- 
ments, the  position  of  the  tube  should  be  kept  unchanged 
until  they  cease  to  come. 

Eeferring  to  obstruction  of  the  tube  by  the 
vesical  \\^allSj  which  are  sometimes  sucked  into  the 
orifice,  TTatson  says: — 

The  stopjjage  from  this  cause  is  usually  not  continuous, 
but  the  walls  flapping  against  the  opening  give  the  instru- 
ment a  series  of  jerks  that  remind  one  of  a  fish-bite.  When 
this  is  felt,  the  instrument  should  be  moved  to  another  part 
of  the  bladder.  If  it  ag-ain  occurs,  the  bladder  is  not  suffi- 
ciently distended,  and  Mater  should  be  added  to  the  hose  at 
the  top  of  the  bulb. 

The  pumping  process  should  be  persisted  in  so 
long  as  gravel  or  sabulous  debris  continues  to  come 
away.  As  soon  as  the  fragments  cease  coming,  the 
lithotrite  should  be  reintroduced  and  further  crush- 
ing performed,  after  which  the  evacuator  is  used  as 
before.  The  principal  difficulty  in  the  operation  of 
litholapaxy  is  the  crushing  of  the  final  fragment.  It 
sometimes  haj^pens  that  a  single  small  fragment 
eludes  discovery  and  crushing,  and  remains  in  the 
bladder  to  form  a  nucleus  for  a  new  calculus.  This 
fact  has  accounted  for  much  of  the  criticism  to  which 
litholapaxy  has  been  subjected.  Careful  search  with 
the  beak  of  the  lithotrite,  alternating,  if  necessary, 
with  a  current  of  water  thrown  through  the  evacu- 
ating tube,  usually  succeeds  im  locating  the  fragment, 
after  which  it  is  comparatively  easy  to  pick  it  up 
with  the  lithotrite  and  crush  it. 

Chismore's  lithotrite  is  a  very  ingenious  device 
for  catching  small  fragments.  It  has  a  central  tube 
traversing  the  male  blade  and  opening  at  its  base. 
To  this  tube  an  aspirating  bottle  is  attached  for  the 
purpose  of  exerting  suction  upon  the  contents  of  the 
bladder,  thus  drawing  the  fragment  between  the 
blades  where  it  may  be  crushed  with  great  facility. 
Chismore  has  also  devised  a  hammer  or  percussor  for 
fracturing  the  calculus  after  it  has  been  caught  in 
the  jaws  of  the  lithotrite. 


Fig.  176. — Chismore's 
lithotrite. 


LITHOTEITY   AXD    LITHQLAPAXT. 


803 


In  withdrawing  evacuating  tubes  great  care  should  be  taken  lest  a  frag- 
ment of  calculus  should  be  impacted  in  the  eye  of  the  instrument  and  pro- 
duce laceration  of  the  neck  of  the  bladder  and  urethra  as  it  is  withdrawn. 
Should  such  impaction  occur,  the  calculus  material  may  be  removed  by  a 
stylet.  In  cases  in  which  straight  tubes  are  with  difficulty  introduced,  tubes 
with  a  short,  curved  point,  corresponding  to  the  ordinary  deep  urethral 
curve,  may  be  used. 


Fig.  177. — Chismore's  pereussor  for  fracturing  calculi. 

Accidents  During  LitJiolapaxy. — There  are  really  no  very  important 
complications  of  the  operation  of  litholapaxy.  Hemorrhage  may  occur 
under  certain  special  conditions,  but  with  proper  delicacy  of  manipulation 
it  certainly  should  be  rarely  experienced.  The  same  remarks  apply  to 
laceration  of  the  urethra.  Should,  however,  the  latter  accident  occur,  a 
retained  catheter,  or,  better,  perineal  drainage,  should  be  instituted  for  a 
few  days.     The  bladder  is  sometimes  injured  by  its  walls'  falling  between 


Fig.    178. — Chismore's   washing  bottle  and  tube. 


the  jaws  of  the  lithotrite.  This  is  not  apt  to  occur  when  the  viscus  is  dis- 
tended with  fluid  to  the  required  extent.  In  the  normal  bladder  it  is  almost 
impossible  to  catch  the  walls  of  the  organ  in  the  lithotrite.  When,  how- 
ever, it  is  the  seat  of  diverticula,  or  is  considerably  columnated,  as  it  occa- 
sionally is  in  old  men,  such  an  accident  may  occur.  Eough  manipulations 
with  the  lithotrite  or  overdistension  with  fluid  may  produce  rupture.  Wat- 
son relates  a  case  in  which  the  bladder  ruptured  by  its  own  spasmodic  con- 


804  UEINARY    CALCULUS. 

traction  when  containing  but  an  ounce  or  two  of  urine.  In  sucli  cases 
laparotomy  should  be  performed  at  once. 

The  chief  danger  is  the  impaction  of  fragments  in  the  eye  of  the 
evacuating  tube  or  between  the  jaws  of  the  lithotrite,  already  mentioned. 
Such  fragments  may  become  dislodged  from  the  instrument  and  impacted 
in  some  part  of  the  urethral  tract.  The  favorite  points  of  lodgment  are  the 
prostatic  urethra,  bulbo-membranous  Junction,  and  fossa  navicularis.  The 
maneuvers  for  avoiding  such  accidents  have  already  been  mentioned.  In 
case  a  fragment  should  become  impacted  in  the  urethra  in  spite  of  all  pre- 
caution, it  may  often  be  removed  by  properly-constructed  forceps.  Peri- 
neal section  may  be  necessary.  In  some  instances  the  fragment  may  readily 
be  pushed  back  into  the  bladder.  The  lithotrite  occasionally  breaks,  in 
which  event  perineal  section,  or  even  suprapubic  cystotomy,  may  be  neces- 
sary. 

As  a  rule,  there  are  no  untoward  results  of  the  operation.  Inflamma- 
tion of  the  bladder,  prostate,  urethra,  and  testes  may  occur.  Peritonitis 
follows  more  often  than  might  be  supposed.  Urine-fever  occurs  in  a  cer- 
tain proportion  of  cases.  The  sounder  the  kidneys,  the  less  the  danger  of 
both  infection  and  uremia. 

On  the  completion  of  the  operation  the  patient  should  be  given  a  little 
whisky  or  brandy  in  a  copious  draught  of  hot  water  and  put  to  bed.  If 
there  is  any  particular  degree  of  shock,  warmth  should  be  applied  to  the 
extremities.  Morphia  and  quinia  may  be  administered  to  prevent  chill.  It 
is  an  excellent  plan  to  give  the  narcotic  by  the  rectum  in  the  form  of  sup- 
positories. The  diet  should  be  limited  strictly  to  milk,  and  urinary  anti- 
septics kept  up.  If  there  are  no  injurious  effects  from  the  operation,  the 
patient  may  be  allowed  to  get  about  within  forty-eight  hours.  Many  sur- 
geons allow  the  patient  to  get  up  at  the  end  of  twenty-four  hours,  but  the 
author  does  not  consider  this  wise. 

Freyer  pronounces  litholapaxy  the  safest  and  best  operation  for  calculi 
of  all  sizes  in  patients  of  all  sorts  and  conditions,  provided  only  that  the 
operation  is  feasible.  When  litholapaxy  is  not  practicable,  he  considers  that 
calculi  up  to  about  three  ounces  in  the  adult,  and  of  corresponding  weight 
in  the  child,  are  best  removed  by  perineal  lithotomy;  beyond  that,  supra- 
pubically.  He  states  that  six  and  one-eighth  oimces  is  the  largest  stone  he 
has  removed  by  Bigelow's  method.  He  holds  that  in  no  case  should  a  stone, 
large  or  small,  be  subjected  to  a  cutting  operation  till,  after  trial,  litholapaxy 
is  found  not  to  be  feasible. 

Freyer's  lithotrites  vary  from  No.  4  ^/o  up  to  18,  of  the  English  scale. 
Only  the  larger  sizes,  from  No.  11  up  to  18,  are  of  any  practical  use  in  deal- 
ing with  large  stones.  His  lithotrites  combine  the  handle  and  locking  ac- 
tion of  Bigelow's  lithotrite,  with  the  fully  fenestrated  blades  of  Weiss  and 
Thompson.  They  have  a  ball  handle  that  affords  a  much  firmer  grip  to  the 
hand  than  the  old-fashioned  wheel:    a  grip  necessary  in  dealing  with  large 


LITHOTEITY    AND    LITHOLAPAXY.  805 

and  hard  calculi.  The  locking  action  is  of  the  simplest  character,  the  in- 
strmnent  being  locked  or  unlocked  by  a  quarter  turn  of  the  wrist,  to  the 
right  or  left,  respectively,  the  left  hand  being  free  to  grasp  the  female 
blade,  and  hold  it  steady  in  the  bladder  during  the  various  manipulations. 
The  tilting  of  the  instrument  that  is  liable  to  occur  when  the  button-lock- 
ing action  is  employed  is  thus  obviated. 

The  cannulas  used  by  Freyer  for  large  calculi  in  the  adult  vary  from 
Nos.  14  to  18  English. 

Exception  should  certainly  be  taken  to  Ereyer^s  statement  that,  where 
litholapaxy  is  not  practicable,  perineal  lithotomy  should  be  performed  for 
calculi  up  to  three  ounces  in  weight  in  the  adult.  The  statistics  of  the  im- 
proved suprapubic  operation  are  by  no  means  complete  or  extensive,  but, 
so  far  as  they  go,  indicate  the  superiority  of  suprapubic  section  in  adult 
patients  below  middle  age. 

Litholapaxy  is  the  operation  of  election  in  all  cases  of  vesical  calculus 
in  the  female.  The  shortness,  and  anatomic  and  physiologic  unimportance 
of  the  female  urethra,  greatly  enhance  the  facility  and  safety  of  the  crush- 
ing operation. 

Peeineal  Lithoteity.  —  A  modification  of  lithotrity  involving  an 
opening  in  the  perineum  was  devised  in  1862  by  Dolbeau.  Eeginald  Har- 
rison has  recently  revived  and  improved  this  operation.  He  speaks  of  it 
as  follows^: — 

"The  name  of  perineal  lithotrity  was  given  by  Dolbeau  to  an  operation,  com- 
pleted in  one  sitting,  by  which  the  membranous  portion  of  the  urethra  is  opened, 
the  prostate  and  the  neck  of  the  bladder  dilated  instead  of  being  cut,  and  a  large 
stone  crushed  and  its  fragments  immediately  evacuated. 

"The  chief  features  of  the  operation  are:  (1)  the  mode  of  obtaining  access  to 
the  interior  of  the  bladder  from  the  perineum,  and  (2)  the  mechanism  connected 
with  crushing  and  evacuating  the  stone.  From  a  number  of  experiments  I  made 
upon  the  dead  subject,  as  well  as  from  the  performance  of  median  cystotomy  on 
the  living,  for  various  purposes,  it  seemed  unnecessary  to  do  more  than  make  an 
opening  from  the  perineum  into  the  membranous  urethra  at  the  apex  of  the  prostate 
on  a  grooved  staff  passed  along  the  urethra,  sufficient  to  admit  the  introduction  of 
Wheelhouse's  small  tapering  gorget,  and  subsequently  the  index  finger,  into  the 
bladder,  as  for  digital  exploration  or  as  is  done  in  the  hontonniere  or  Cock's  opera- 
tion; more  than  this  is  not  necessary.  In  Dolbeau's  operation  direct  access  was 
obtained  by  this  route,  aided  by  the  use  of  an  expanding  instrument,  by  means  of 
which  the  prostatic  urethra  and  neck  of  the  bladder  were  dilated.  It  seems  to  me, 
from  experiments  upon  the  cadaver,  that  the  latter  means  of  dilation  is  not  only 
unnecessary,  but  is  open  to  the  objection  that,  unless  used  with  the  greatest  care, 
it  is  possible  to  inflict  serious  damage  by  it.  Further,  I  succeeded  in  demonstrating 
that  by  means  of  crushing-forceps,  shaped  somewhat  like  the  blades  of  the  lithotrite, 
and  not  exceeding  by  actual  measurement  in  circumference  that  of  an  ordinary 
index  finger,  sufficient  power  might  be  provided  to  crush  and  assist  in  evacuating 
any  stone  that  could  be  fairly  seized  in  this  way.  These  forceps  are  provided  with 
a  cutting  rib  within  the  blades,  and  the  more  powerful  instruments  are  fitted  with 


'  Lancet,  September  22,  1888,  and  April  7,  1894. 


806  UEIXAEY    CALCrLITS. 

a  movable  screw  on  the  handle.  The  fragments  may  subsequently  be  withdrawn  by 
means  of  aspirator-catheters  passed  through  the  wound,  or  even  by  forceps.  If  care 
is  taken  to  make  the  perineal  wound  correspond  in  size  with  the  evacuating  catheters, 
which  should  be  of  about  the  size  of  an  ordinary  index  finger,  there  is  no  difficulty  in 
keeping  the  bladder  distended  during  the  necessary  manipulations. 

The  chief  points  that  Harrison  gives  in  favor  of  this  operation  are 
these:  (1)  it  enables  the  operator  to  crush  and  evacuate  large  stones  in  a 
short  space  of  time;  (2)  it  is  attended  with  very  little  risk  to  life  as  com- 
pared with  other  operations  where  any  cutting  is  done^  such  as  lateral  or 
suprapubic  lithotomy;  (3)  it  is  well  adapted  to  old  and  feeble  subjects; 
(4)  it  permits  the  operator  to  wash  out  the  bladder,  and  any  pouches  con- 
nected with  it,  more  effectually  than  by  the  urethra,  as  the  route  is  shorter 
and  the  evacuating  catheters  employ^  are  of  much  larger,  caliber;  (5)  the 
surgeon  can  usually  ascertain,  either  by  exploration  with  the  finger  or  by 
the  introduction  of  forceps  into  the  bladder,  that  the  viscus  is  cleared 
of  all  debris;  (6)  it  enables  the  surgeon  to  deal  with  certain  forms  of  pro- 
static outgrowth  and  obstruction,  complicated  with  atony  of  the  bladder, 
in  such  a  way  as  not  only  to  facilitate  the  removal  of  the  stone,  but  to 
restore  the  function  of  micturition;  (7)  by  the  subsequent  introduction 
and  temporary  retention  of  a  soft-rubber  drainage-tube,  cystitis  due  to 
the  retention  of  urine  in  pouches  and  depressions  in  the  bladder-wall  is 
either  entirely  cured  or  at  least  permanentl}^  improved.  The  retention  of 
ammoniacal  urine  in  a  bladder  that  cannot  properly  empty  itself  after 
lithotrity  favors  the  formation  of  recurrent  phosphatic  stone.  Harrison 
claims  that  he  has  never  known  the  wound  to  remain  unhealed,  except  in 
those  cases  where,  for  some  reason  or  other,  it  has  been  desired  to  construct 
a  low-level  urethra.  It  is  well  adapted  for  some  cases  of  stone  complicated 
by  deep  urethral  stricture,  as  it  facilitates  operation  upon  both  conditions 
at  the  same  time,  and  does  not  expose  the  patient  to  danger  incurred  by 
lithotrity  via  a  weakened  or  permanently  damaged  urethra. 

LITHOTOMY. 

The  operation  of  litholapaxy  has  unquestionably  greatly  narrowed  the 
field  of  usefulness  of  all  cutting  operations  for  stone.  The  extent  to  which 
lithotomy  has  been  restricted  in  the  practice  of  some  of  our  leading  au- 
thorities is  well  illustrated  by  the  statement  of  Sir  Henry  Thompson  that, 
whereas  he  formerly  found  it  necessar}^  to  cut  25  per  cent,  of  patients  with 
calculus,  he  now  performs  lithotomy  in  a  little  over  3  per  cent,  of  cases. 
It  is  the  author's  opinion,  however,  that  the  advocates  of  the  crushing  op- 
eration have  become  oversanguine  on  account  of  the  remarkable  success 
attained  by  relatively  few  extraordinarily  expert  operators.  The  statistics 
of  litholapaxy  in  the  hands  of  such  operators  as  Thompson,  Keegan,  and 
Freyer  are  somewhat  misleading,  for  the  reason  that  their  opportunities 
have  been  such  as  to  give  them  a  manifest  advantage  in  perfecting  their 


LITHOTOMY.  807 

operative  technic  and  acquiring  the  tactile  skill  necessary  to  the  highest 
degree  of  perfection  of  operative  manipulations.  Operations  for  stone,  how- 
ever, cannot  be  restricted  to  the  practice  of  the  few.  The  general  surgeon 
and  the  specialist  of  lesser  opportunities  than  the  extremists  in  the  advocacy 
of  litholapaxy  must  necessarily  be  called  upon  to  operate  for  stone.  The 
feasibility  of  one  or  the  other  operation,  and  the  comparative  merits  of  the 
cutting  and  crushing  methods  cannot  be  decided,  therefore,  by  statistics 
obtained  by  the  fortunate  few.  Under  certain  circumstances,  and  with  cer- 
tain operators,  lithotomy  must  necessarily  be  given  the  preference.  It  must 
also  be  remembered  that  what  has  been  said  regarding  the  relative  expert- 
ness  of  litholapaxists  applies  with  equal  force  to  lithotomists.  There  are 
certain  operators  in  whose  hands  the  perineal  operation  for  stone,  especially 
in  children,  yields  statistics  that  are  in  nowise  inferior  to  those  afforded  by 
litholapaxy  in  the  hands  of  a  limited  number  of  expert  operators.  It  is  true 
that  accidents  are  more  apt  to  occur,  on  the  average,  during  the  performance 
of  the  cutting  operation  than  during  litholapaxy.  Here,  again,  however, 
comes  into  question  the  relative  merits  of  different  operators.  In  the  matter 
of  statistics  much  depends  upon  the  method  of  selection  of  cases.  The 
results  obtained  by  lithotomy  in  the  practice  of  Benjamin  Dudley,  of  Lex- 
ington, left  little  to  be  desired  from  a  statistic  stand-point.  In  one  series 
of  one  hundred  cases  of  all  ages  he  did  not  have  a  death.  As  is  well  known, 
however,  Dudley  exhibited  great  care  in  the  selection  of  his  cases  and  in 
the  preliminary  preparation  of  the  patient.  The  records  of  such  American 
operators  as  the  late  William  T.  Briggs,  of  Nashville,  Tenn.,  taking  into 
consideration  the  multitudinous  variety  of  cases  upon  which  he  operated, 
are  such  as  the  advocates  of  the  cutting  operation  have  no  cause  to  be 
ashamed  of.  The  old-time  operation  of  suprapubic  lithotomy,  as  recently 
revived,  with  all  the  advantages  of  modern  surgical  asepsis  and  antisepsis, 
may  be  said  to  be  still  in  its  infancy.  All  statistics  of  this  particular  opera- 
tion formulated  prior  to  the  antiseptic  and  aseptic  era  of  surgery  should  be 
thrown  aside  as  worthless.  The  statistics  of  the  operation  as  modified  and 
improved  of  recent  years  are  too  meager  as  yet,  and  too  obscured  and  viti- 
ated by  operations  performed  by  surgeons  for  whom  the  principal  attrac- 
tion of  the  method  has  been  its  apparent  simplicity,  to  permit  of  any  deduc- 
tions regarding  the  comparative  merits  of  this  operation  in  suitable  cases 
and  those  of  litholapaxy.  It  were  wise,  therefore,  not  to  be  too  sweeping 
in  the  advocacy  of  litholapaxy  to  the  exclusion  of  lithotomy. 

Yaeieties  of  Lithotomy. — The  methods  of  cutting  for  stones  are  (1) 
perineal  lithotomy,  lateral  or  median,  or  a  combination  of  the  two;  (2) 
suprapubic  lithotomy;  (3)  combined  perineal  section  and  crushing;  (4) 
combined  suprapubic  section  and  crushing. 

Indications  for  Lithotomy. — 1.  In  children.  In  a  general  way  the 
selection  of  the  operation  must  depend,  to  a  certain  extent,  upon  the  experi- 
ence of  the  operator.    It  is  questionable  whether  an  operator  who  has  been 


808  UEIN-AET    CALCITLUS. 

extraordinarily  successful  with  perineal  lithotomy  in  children  would  be 
justified  in  beginning  his  experience  with  litholapaxy  in  young  subjects. 
Where  the  surgeon  has  acquired  a  fair  amount  of  dexterity  in  litholapaxy 
upon  the  adult,  however,  he  may  properly  enter  the  newer  field  of  lithola- 
paxy in  children.  At  the  hands  of  operators  of  average  experience  perineal 
lithotomy  is  likely  to  continue  to  be  the  operation  of  election.  As  for  the 
surgeon  of  limited  experience  with  calculus,  both  as  regards  lithotomy  and 
litholapaxy,  the  former  operation  is  likely  to  yield  the  best  results.  Despite 
the  optimistic  views  of  the  more  enthusiastic  litholapaxists,  there  is  the 
ever-present  danger  of  leaving  fragments  behind,  to  form  nuclei  for  recur- 
rent calculus.  This  occurs  far  oftener  than  some  writers  would  have  us 
believe. 

2.  Stones  complicated  by  deep  stricture.  Here  perineal  lithotomy  dis- 
poses of  both  stricture  and  stone  simultaneously. 

3.  Stones  complicated  by  serious  prostatic  or  vesical  disease.  (Supra- 
pubic lithotomy.) 

4.  Very  large  stones  of  whatever  consistency  in  adults.  (Suprapubic 
lithotomy.) 

5.  Very  hard  stones  of  moderate  size.  (Perineal  or  suprapubic  lithot- 
omy.) 

6.  Encysted  calculi.     (Suprapubic  lithotomy.) 

7.  Cases  where  a  lithotrite  has  broken  during  litholapaxy.  (Perineal, 
suprapubic,  or  combined  high  and  low  lithotomy.) 

8.  Cases  where  atony  or  paralysis  of  the  vesical  walls  so  interferes  with 
the  expulsive  power  of  the  viscus  that  it  cannot  be  relied  on  to  assist  in  the 
expulsion  of  fragments  in  litholapaxy.     (Suprapubic  lithotomy.) 

9.  Cases  of  contracted  bladder  where  it  is  impossible  to  distend  the 
viscus  with  fluid.     (Perineal  lithotomy.) 

10.  Cases  of  vesical  hyperesthesia  (irritable  bladder)  in  old  subjects, 
where  the  bladder  will  not  retain  sufficient  fluid  to  permit  of  the  manipula- 
tions necessary  in  litholapaxy.  In  most  such  cases,  anesthesia  will  relieve 
the  difficulty,  but  anesthesia  so  prolonged  as  is  likely  to  be  required  for 
crushing  is  extremely  dangerous  save  in  young  adults  with  sound  kidneys. 
(Suprapubic  lithotomy.) 

Within  the  last  five  years  there  has  been  considerable  change  in  the 
attitude  of  the  profession  toward  lithotomy  in  children.  It  is  not  so  many 
years  since  the  author  stated  in  his  lectures  that  children  under  puberty 
with  calculus  must  always  be  subjected  to  lithotomy  if  the  best  results 
were  desired  with  the  least  inconvenience  and  danger.  The  profession,  in 
general,  accepted  until  recently  the  dictum  of  Aston  Key: — 

In  children  it  is  difficult  to  mention  any  operation  in  surgery  so  uniformly 
successful  as  is  lithotomy.  The  incomplete  development  and  the  consequently  little 
susceptibility  of  the  parts  involved,  the  small  size  of  the  vessels  and  the  little  risk 
of  hemorrhage,  the  yielding  nature  of  the  textures,  rendering  force  unnecessary  in 


LITHOTOMY.  809 

the  extraction  of  the  stone,  are  circumstances  that  combine  to  divest  the  operation 
of  much  of  the  danger  that  surrounds  it  when  performed  in  the  adult. 

The  chief  objections  offered  to  the  crushing  operation  in  children  have 
been  hitherto:  (1)  the  difficulty  of  controlling  the  patient  without  a  gen- 
eral anesthetiC;,  (2)  the  prolonged  anesthesia  often  necessary,  (3)  the  small 
size  of  the  urethra  and  vesical  neck,  (4)  the  weakness  of  instruments  inci- 
dental to  the  small  size  necessary  to  the  work  in  the  child,  and  (5)  the 
relative  hardness  of  stone  in  children. 

The  first  reaction  against  perineal  lithotomy  in  children  was  based 
mainly  upon  the  results  obtained  by  Keegan,  who  claimed  that  litholapaxy 
should  be  the  operation  of  election  even  in  children.  Keegan's  dictum, 
being  supported  by  the  moderate  experience  of  a  few  litholapaxists,  has  im- 
pelled some  authors  to  accept  litholapaxy  as  the  only  operation  in  children. 
Taking  Keegan's  own  statistics  as  a  basis,  let  us  see  whether  the  claims  for 
litholapaxy  are  as  yet  substantiated.  It  must  be  remembered  that,  in  com- 
paring Keegan's  results  with  those  of  other  operators,  we  are  necessarily 
comparing  the  results  obtained  by  the  man  who  should  be  the  most  expert 
in  its  performance  with  those  obtained  by  operators  of  less  experience  and 
skill.  In  115  cases  of  litholapaxy  in  children,  ages  not  stated,  Keegan 
lost  4,  or  3  Vio  per  cent.  On  the  other  hand,  in  a  total  of  355  cases  of 
perineal  lithotomy  in  children,  performed  by  four  operators,  and  at  the 
Massachusetts  General  Hospital  by  several  different  operators,  the  mortality 
was  11,  or  3.1  per  cent.  Freyer's  tables,  comprising  987  cases  of  perineal 
lithotomy  occurring  in  1883  in  the  Northwest  provinces  of  India,  showed 
the  rate  of  mortality  up  to  20  years  to  be  5.1  per  cent. 

These  figures  give  very  little  assistance  in  estimating  the  mortality  in 
children.  Eosenthal,  from  a  study  of  400  cases,  estimates  the  mortality  as 
follows: — 

From  1  to  5  years  of  age,  3.5  per  cent. 

From  6  to  11  years  of  age,  2.1  per  cent. 

From  12  to  16  years  of  age,  8.4  per  cent. 

It  must  be  taken  into  consideration  that  the  statistics  compiled  by 
Keegan  and  Freyer  from  operations  upon  native  Indian  children  are  not 
to  be  taken  as  an  accurate  index  of  the  results  to  be  expected  in  operations 
by  European  or  American  surgeons.  In  any  event,  they  are  not  superior  to 
the  statistics  of  lithotomy  in  children.  Climate  and  racial  resistancy  prob- 
ably make  a  difference  in  results.  This  is  equally  true  of  litholapaxy  and 
lithotomy. 

The  author  ventures  the  opinion  that,  despite  the  advances  that  have 
been  made  in  the  operation  of  litholapaxy,  and  the  sweeping  claims  that  are 
being  made  for  the  operation  by  some  of  its  enthusiastic  advocates  and 
their  inexperienced  disciples,  perineal  lithotomy  is  still,  on  the  average,  the 
operation  of  election  in  children  until  at  or  near  the  period  of  puberty,  due 


810  UEIXAEY    CALCULUS. 

allowance  being  made  for  jDrecocity  of  development  in  its  bearing  upon  the 
capacity  of  the  urethra  and  vesical  neck.  Lithotomy  in  the  adult  may,  on 
the  other  hand,  be  considered  to  be  the  operation  of  necessity,  which  is  only 
to  be  performed  when,  for  special  reasons,  already  considered,  litholapaxy 
is  inapplicable.  This  statement  may  later  demand  modification  as  the  op- 
eration of  suprapubic  lithotomy  becomes  more  perfect  in  technic  and  more 
universally  practiced. 

As  litholapaxy  is  the  operation  of  election  in  the  adult,  lithotomy 
being  performed  only  when  the  crushing  operation  is,  for  one  reason  or 
another,  inapplicable,  the  mortality-rate  of  the  cutting  operation  must 
necessarily  be  greater  at  the  present  time  than  when  it  was  practiced  in 
cases  of  all  kinds,  including  the  favorable  ones.  As  the  limitations  of 
lithotomy  decrease,  its  mortality-rate  will,  of  course,  increase,  although  the 
increase  will  be  limited  somewhat  by  increasing  perfection  in  aseptic  and 
antiseptic  technic  in  the  cutting  operation.  Increasing  experience  with  the 
sujDrapubie  operation  in  the  adult  will,  in  all  probability,  offset,  to  a  certain 
extent,  the  increasing  mortality-rates  of  lithotomy  incidental  to  the  en- 
croachment of  litholapaxy  upon  the  operative  field. 

History  of  Litliotomy. — Lithotomy  is  probably  a  very  ancient  opera- 
tion. The  Hindoos  were  alluded  to  as  lithotomists  by  Hippocrates.  It  is 
certain  that  Susruta.  a  learned  Hindoo  physician,  described  the  operation 
1000  B.C.  He  described  the  suprapubic  as  well  as  the  perineal  operation. 
Little  was  known  of  lithotom}^  however,  until  the  middle  of  the  Sixteenth 
Centur}^  when  it  was  revived,  mainly  through  the  efforts  of  a  Florentine 
monk,  Frere  Jacques,  who  performed  perineal  section.  About  this  time, 
also,  Pierre  Franco  performed  not  only  the  perineal  operation,  but  also  supra- 
pubic section.  In  1560  he  performed  the  latter  operation  on  a  child,  and 
removed  a  stone  the  size  of  a  hen's  egg,  which  he  had  previously  failed  to 
remove  by  perineal  section.  Frere  Jacques  is  credited  with  having  done 
several  thousand  perineal  sections  for  stone.  It  seems  that  the  chief  com- 
petitors of  the  monks  in  those  ancient  days  were  the  barber-surgeons,  one 
of  whom,  Eau,  was  said  to  have  been  a  very  successful  operator.  Perineal 
lithotomy  was  finally  reduced  to  a  scientific  basis  from  both  an  anatomic 
and  surgical  stand-point  by  Cheselden,  an  English  surgeon.  The  operation 
has  since  been  modified  to  a  greater  or  less  degree  by  different  surgeons, 
largely  to  suit  their  own  ideas  of  the  direction  and  length  of  the  incisions 
and  the  instruments  that  are  most  useful  in  operating,  but  the  operation 
of  lateral  section  in  vogue  to-day  is  none  the  less  essentially  that  of  the 
distinguished  Cheselden.  The  lateral  operation,  through  one  lobe  of  the 
prostate,  practically  displaced  for  a  long  time  the  Marian  or  median  sec- 
tion introduced  nearly  four  hundred  years  ago  by  Marianus  Sanctus  de 
Barletta.  This  operation  in  more  recent  years  was  revived  and  improved  by 
Allarton,  also  an  English  surgeon.  Allarton's  median  section  is  the  type  of 
that  occasionall}'  practiced  at  the  present  daj^,  and  was  the  progenitor  of 


LITHOTOMY. 


811 


median  perineal  cystotomy  as  it  now  exists.  Dupuytren  modified  the 
median  operation  by  making  a  bilateral  section  of  the  prostate.  Civiale  de- 
signed and  advocated  a  special  variety  of  bilateral  section  that  he  termed 
the  medio-bilateral  operation.  Special  instruments  were  devised  by  both 
of  these  operators  for  the  performance  of  their  peculiar  modifications  of 
perineal  section.  The  ancient  operation  that  became  most  unpopular  was 
the  high,  or  suprapubic,  section.  Under  recent  aseptic  and  antiseptic  sur- 
gical methods,  however,  the  operation  has  been  revived  and  is  becoming 
deservedly  popular  with  some  of  our  most  progressive  surgeons.  In  a  gen- 
eral way,  it  may  be  said  that  it  is  not  wise  for  the  surgeon  to  adopt  any 
cutting  operation  as  a  matter  of  routine.     To  accomplish  the  best  results 


Fiff.  179. — Clover's  crutch. 


he  should  be  familiar  with  all  the  various  methods,  and,  while  he  may  ex- 
hibit a  preference  for  some  particular  method,  he  should  modify  his  technic 
whenever  any  circumstances  involving  the  age,  constitution,  or  present  con- 
dition of  the  patient  seem  to  demand  it.  Especially  should  he  be  ready  to 
modify  his  technic  where  the  size  of  the  stone  indicates  it. 

cheselden's  operation  of  lateral  lithotomy. 

The  instruments  and  appliances  necessary  for  lateral  lithotomy  are  as 
follow: — 

1.  An  operating-table  high  enough  to  reach  the  level  of  the  opera- 
tor's breast  when  in  the  sitting  posture. 

2.  Several  roller  bandages  of  heavy  flannel,  four  inches  wide  and  four 


812  .  TEIXARY    CALCULUS. 

yards  long^  for  the  purpose  of  tying  the  patient  in  position.  These  may 
be  substituted  by  a  sort  of  yoke  or  crutch  (Clover's)  with  leathern  leg-  and 
wrist-  bands  devised  for  this  purpose  (Fig.  179). 

3.  Two  straight-backed,  sharp-pointed,  stiff  scalpels  of  different  sizes. 

4.  A  slightly  curved,  probe-pointed  scalpel. 

5.  Several  lithotomy-staffs  with  lateral  groove. 

6.  Lithotomy-forceps. 

7.  Scoops  of  various  sizes. 

8.  A  Thompson  searcher. 

9.  A  large  fountain-syringe  or  glass  irrigator. 

10.  A  grooved,  angular  lithotomy-director. 

11.  A  blunt  gorget. 


Fig.  ISO. — Position  of  patient  and  line  of  incision  in  lateral 
lithotomy.     (After  Bryant.) 

12.  Half  a  dozen  hemostatic  forceps. 

13.  Perineal  tube  grooved  for  a  petticoat. 

If  it  be  advisable  to  modify  the  operation  in  any  way,  as  by  making 
bilateral  incisions,  etc.,  the  special,  instruments  devised  for  the  purpose  may 
be  used.  Their  necessity,  however,  is  questionable,  as  all  necessary  cutting 
can  be  done  with  an  ordinary  scalpel  in  the  hands  of  a  careful  operator. 
Instruments  for  crushing  and  evacuating  should  be  at  hand.  The  prep- 
aration of  the  patient  should  be  precisely  the  same  as  outlined  in  connec- 
tion with  urethral  operations  and  lithotomy. 

Just  prior  to  the  operation  the  urine  should  be  drawn  off,  and  if  the 


LITHOTOMY. 


813 


bladder  is  infected  it  should  be  irrigated  with  a  warm  solution  of  bichlorid, 
1  to  20,000,  or  of  boric  acid,  until  tolerably  clean.  Six  to  8  ounces  of  this 
solution  should  be  allowed  to  remain  in  the  bladder. 

Having  been  placed  upon  the  table  upon  his  back,  in  a  good  light,  and 
anesthetized,  the  patient's  hands  and  feet  are  strapped  or  bound  together, 
and  each  leg  supported  by  an  assistant  in  such  a  manner  that  the  nates 


Fig.   181.— Lithotomy-staff. 


project  over  the  edge  of  the  table  (Fig.  180).  The  perineum  is  supposed 
to  have  been  shaved,  scrubbed,  and  aseptized,  and  the  rectum  emptied  before 
the  patient  is  placed  upon  the  table. 

A  staff  with  a  left  lateral  groove,  as  large  as  the  urethra  will  admit, 
is  next  introduced  and  made  to  strike  the  stone.    If  the  instrument  cannot 


Fig. 


Probe-pointed   straight  lithotomy^knife. 


be  made  to  impinge  upon  the  calculus,  the  operation  should  be  abandoned 
for  the  time  being,  as  there  is  always  a  possibility  of  a  small  stone's  having 
escaped  since  exploration.  The  staff,  having  been  placed  in  the  desired 
position,  is  given  to  an  assistant,  who  also  holds  the  penis  and  scrotum  up 
out  of  the  way.  A  nurse  or  assistant  should  stand  at  the  surgeon's  right, 
and  hand  him  the  instruments  as  required.  Some  surgeons,  however,  pre- 
fer to  take  the  instruments  from  the  tray  as  required.    The  average  nurse 


Fig.  183. — Probe-pointed  curved  lithotomy-scalpel. 

or  assistant  is  something  of  a  nuisance  in  selecting  and  handing  instruments 
to  the  operator. 

The  Incision. — The  external  incision  is  now  made  by  entering  the 
point  of  the  knife  in  the  direction  of  the  groove  of  the  staff  one  and  a  half 
inches  in  front — i.e.,  above — the  anus  in  the  perineal  raphe.  The  knife 
is  then  made  to  cut  downward  and  outward  to  a  point  corresponding  to  the 
junction  of  the  outer  with  the  middle  third  of  the  space  between  the  tuber- 


814  TJEIXAET    CALCULUS. 

osity  of  the  ischium  and  the  anus,  tlie  knife  being  drawn  out  of  the  tissues 
gradually  as  the  cut  is  being  made,  thus  leaving  the  tail  of  the  incision,  so 
to  speak,  at  the  lower  angle.  Oftentimes  the  membranous  urethra  is  en- 
tered at  this  first  stroke;  generally,  however,  it  is  simply  exposed.  The 
forefinger  of  the  left  hand  now  feels  for  the  groove  in  the  staff,  and,  the 
finger-nail  being  engaged  in  the  groove,  the  knife  is  passed  over  it  and 
made  to  open  up  the  urethra.  Having  engaged  the  point  of  the  knife  in 
the  groove  of  the  staff',  with  the  edge  of  the  blade  turned  downward  and  to 
the  right, — parallel  with  the  ischiatic  ramus,  to  avoid  cutting  the  rectum 
on  the  one  side  and  the  internal  pudic  artery  upon  the  other, — the  blade  is 
pushed  along  the  groove  of  the  staff  into  the  bladder  (Fig.  185).  The  angle 
of  separation  between  the  heel  of  the  knife-blade  and  staff  should  be  slight, 
as  this  angle  will  regulate  the  extent  of  the  deep  wound  in  great  measure. 


Fig.  184. — Conventional  diagram  of  the  j^erineuui  and  the  incisions  in 
lateral  lithotomy.     (After  Thompson.) 

In  withdrawing  the  knife  the  handle  may  be  depressed  a  little,  thus  slightly 
enlarging  the  prostatic  incision.  Another  excellent  plan  is  to  withdraw  the 
staff  until  the  point  is  barely  covered  by  the  tissues  between  the  incision 
and  the  vesical  neck,  and  then,  fixing  the  point  of  the  knife  at  the  desired 
angle  with  the  staff,  passing  both  into  the  bladder  simultaneously.  As  the 
knife  enters  the  bladder,  the  fact  will  be  announced  by  a  gush  of  antiseptic 
fluid,  or  urine,  from  the  wound.  Having  entered  the  bladder,  the  knife  is 
to  be  carefully  withdrawn,  still  hugging  the  groove  of  the  staff;  the  left 
forefinger  is  then  to  be  substituted  for  the  knife  and  pushed  with  a  slightly 
boring  motion  into  the  bladder  along  the  staff  and  line  of  incision;  and 
an  attempt  is  made  to  feel  the  stone.  Should  the  operator  be  unable  to 
reach  the  bladder  on  account  of  a  large  prostate,  deep  perineum,  or  the 
shortness  of  his  forefinger,  a  blunt  gorget,  or  grooved  director,  should  be 


LITHOTOMY. 


815 


passed  in  and  the  prostate  dilated.  This  was  the  practice  of  Cheselden  and 
Martineau. 

To  recapitulate  the  steps  of  the  operation  up  to  the  time  the  operator 
has  reached  the  stone: — 

1.  The  knife  is  entered  at  a  point  in  the  perineal  raphe  about  one  and 
one-half  inches  in  front  (above)  the  anus,  the  point  being  pushed  toward 
the  groove  in  the  staff.  It  is  then  swept  downward  and  outward  to  a  point 
just  below  the  anus,  terminating  about  one-third — preferably  a  little  more 
than  one-third — nearer  the  tuberosity  of  the  ischium  than  the  anus,  and 
becoming  superficial  as  it  is  withdrawn.     The  upper  end  of  this  incision 


Fig.  185. — Lateral  lithotomy  with  a  curved  staff.     (After  Bryant.) 


is  about  three-quarters  of  an  inch  to  one  inch  in  depth.  By  this  first  in- 
cision are  divided  the  skin,  superficial  fascia,  and  fat,  and  the  inferior 
hemorrhoidal  vessels  and  nerves. 

2.  Any  undivided  structures  between  the  first  incision  and  the  mem- 
branous urethra  are  divided  by  the  knife,  the  left  forefinger  guiding  the 
knife  in  the  wound  so  as  to  protect  the  rectum.  In  this  step  the  trans- 
versus  perinei  muscles,  some  areolar  tissue,  and  a  few  small  vessels  are  cut, 
and  the  space  between  the  accelerator-uringe  and  erector-penis  muscles 
opened  up.  The  triangular  ligament  is  also  incised,  opening  its  cavity  and 
exposing  the  membranous  urethra.  In  thin  subjects  the  author  does  not 
hesitate  to  cut  through  these  structures  in  the  first  incision.     There  is  no 


816 


UEIXAEY    CALCULUS. 


danger  in  so  doing,  providing  the  operator  is  steady,  and  strikes  the  groove 
of  tlie  staff  accurately. 

3.  The  left  foretinger-nail  is  engaged  in  the  groove  of  the  staff,  which 
is  readily  felt  through  the  membranous  urethra. 

4.  The  membranous  urethra,  if  not  already  opened,  is  incised  just  in 
front  of  the  prostatic  apex. 

5.  The  point  of  the  knife  is  engaged  in  the  groove  of  the  staff  and 
made  to  hug  it  firmly.  It  is  then  passed  along  it  at  a  slight  angle,  with  the 
blade  turned  laterally  and  to  the  right — through  the  prostate  into  the 
bladder,  penetration  of  the  bladder  being  announced  by  a  gush  of  fluid. 

6.  The  knife  is  slowly  withdrawn,  the  cut  in  the  prostate  being  en- 
larged slightly  by  depressing  the  handle.  The  left  forefinger  is  then  bored 
carefully  through  the  prostate  into  the  bladder,  and  an  attempt  made  to 


Fig.  186. — The  bony  pelvis  in  its  relations  to  perin,eal  lithotomy. 
(After  Thompson.) 


feel  the  stone.  If  this  cannot  be  done,  a  blunt  gorget  or  director  should 
be  used.  Once  the  bladder  is  entered  by  the  finger,  the  staff  may  be 
removed. 

The  principal  danger  in  lateral  lithotomy  is  in  incising  the  prostate  so 
freely  that  its  investing  capsule  is  divided.  This  may  always  be  avoided  by 
taking  care  not  to  have  too  great  an  angle  between  the  blade  of  the  knife 
and  the  groove  of  the  staff  in  pushing  the  former  into  the  bladder,  and 
avoiding  separation  of  the  knife  from  the  groove  during  withdrawal.  Should 
the  accident  happen,  either  through  incision  or  laceration  during  rough 
efforts  at  the  extraction  of  a  large  stone,  urinary  extravasation — pelvic — and 
death  are  considered  almost  inevitable.  It  is  possible,  however,  that  this 
accident  happens,  and  is  followed  by  recovery,  more  frequently  than  is  gen- 
erally supposed. 


LITHOTOMY. 


817 


Extraction  of  the  Stone. — The  next  step  in  the  operation  is  the  ex- 
traction of  the  stone.  Having  determined  its  size  and  position,  the  opera- 
tor passes  a  forceps,  of  a  size  proportionate  to  that  of  the  stone,  into  the 
bladder,  guided  by  his  left  forefinger,  which  has  never  been  allowed  to 
leave  the  wonnd  for  an  instant.  This  latter  is  a  very  important  point, 
especially  in  children,  as  it  may  not  be  an  easy  matter  to  enter  the  blad- 


Fig.  187. — Incision  in  the  prostate  in  lateral  lithotomy. 
(After  Erichsen.) 

der  again  when  once  the  finger  has  been  removed.  When  the  forceps 
has  entered  the  bladder,  the  finger  is  withdrawn,  and  an  attempt  made 
to  seize  the  calculus,  this  being  usually  immediately  successful.  If  the 
stone  be  small,  it  may  be  grasped  regardless  of  its  form,  but  if  of  mod- 
erate size,  it  must  be  grasped  transversely:  i.e.,  by  its  short  diameter.  This 
is  very  necessarj'  if  the  stone  be  oblong.    Should  there  be  difficulty  in  grasp- 


Fig.  188. — Broad-grooved  lithotomy-director. 


ing  it,  the  finger  of  an  assistant  passed  into  the  rectum  may  be  of  service. 
When  necessary,  the  operator  may  pass  his  own  middle  finger  into  the  rec- 
tum, and  press  the  stone  into  the  jaws  of  the  forceps.  He  should  take 
care,  however,  not  to  insert  the  same  finger  into  the  wound.  This  advice 
may  seem  superfluous,  but  the  author  recalls  the  maneuvers  of  a  distin- 
guished gynecologist  who  is  something  of  a  monomaniac  on  the  subject  of 


818 


UEIXAKT    CALCULUS. 


antisepsis,  but  who  passes  liis  imwashed  finger  alternately  into  the  rectnm 
and  vagina  during  both  operations  and  labor.  The  author  also  recalls  see- 
ing a  well-known  Eastern  surgeon  do  what  was  much  worse,  although  not 
fraught  with  equal  danger:  operating  for  a  fistula  in  ano  and  enlarged 
tonsils  in  succession,  without  washing  his  hands. 

When  the  wound  is  so  deep  that  it  is  impracticable  to  reach  the  blad- 
der with  the  finger,  the  forceps  may  be  passed  along  the  groove  in  the 
staff,  or  a  director  may  be  passed,  the  staff  withdrawn,  and  the  forceps 
passed  along  the  director.     Care  should  be  taken  not  to  fracture  the  cal- 


Fig.  189. — Combined,  lithotomy-scoop  and  lithotomy-director. 

cuius  in  grasping  it  with  the  forceps,  although  it  must  be  admitted  that  this 
accident  is  often  unavoidable  on  account  of  the  friability  of  the  stone. 
Should  the  stone  be  fractured  despite  all  caution,  the  pieces  are  best  re- 
moved by  means  of  the  finger  and  a  scoop.  This  procedure  is  necessarily 
attended  by  more  interference  with  the  bladder  than  where  the  stone  is 
extracted  whole.  In  exceptional  instances  it  is  necessary  to  fracture  a  large 
calculus  intentionally — perineal  lithotrity — as  the  safest  procedure  under 
existing  circumstances.  Whenever  fracture  occurs,  free  washing  of  the 
bladder  and  removal  of  detritus  via  an  evacuating-tube  are  necessary.  Warm 
antiseptic  solutions  should  be  used  for  washing.    After  the  stone  has  been 


Fig.  190. — ^Lithotomy-forceps:    double  curved. 


successfully  grasped  in  its  most  favorable  diameter,  it  is  to  be  extracted 
slowly,  the  traction  being  directed  in  the  axis  of  the  pelvis,  with  a  slight 
degree  of  lateral  movement.  In  a  measure,  the  maneuver  is  like  the  ap- 
plication and  use  of  the  obstetric  forceps.  It  is  here  that  the  careless  sur- 
geon is  most  apt  to  do  damage  by  tearing  the  prostate,  with  consequent 
invasion  of  the  tissue-investments  that  lie  between  the  operator  and  danger. 
After  the  stone  has  been  extracted,  it  should  be  carefully  examined  for 
facets,  which  are  indicative  of  companion-stones.  The  bladder  should  be 
carefully  explored  with  the  finger  and  sound,  lest  some  small  stone,  or  frag- 


LITHOTOMY.  819 

ment;,  be  left  behind.  The  smallest  fragment  suffices  for  a  nucleus  for  a 
future  large  stone. 

The  bladder  having  been  emptied  of  calculous  material,  is  to  be  thor- 
oughly washed  out  with  a  warm  antiseptic  solution,  after  which  a  drainage- 
tube,  or  special  lithotomy-tube,  should  be  introduced  and  tied  in  with  tapes. 
This  tube  prevents  infiltration  of  urine,  and  at  the  same  time  affords  free 
drainage  to  the  wound.     Siphon-drainage  should  be  instituted. 

After  lithotomy  has  been  completed,  the  patient  is  to  be  put  to  bed, 
and  a  restricted  regimen  prescribed  for  four  or  five  days,  unless,  as  is  occa- 
sionally the  case,  there  is  great  prostration  or  debility,  in  which  event  egg- 
nog  or  punch  may  be  allowed.  Quinin,  for  its  tonic  effect,  and  at  first  small 
doses  of  morphin  to  prevent  chill  and  relieve  pain  are  indicated.  Euca- 
lyptus and  salol  should  be  persisted  in,  if  tolerated  by  the  stomach.  At  the 
end  of  forty-eight  hours  the  drainage-tube  may  be  removed,  as  the  possi- 
bility of  urinary  extravasation  has  by  this  time  been  prevented  by  the 
glazing  of  the  wound  with  lymph-exudate.  The  urine  usually  escapes 
through  the  wound  for  two  weeks  or  more.     Sometimes,  however,  it  sud- 


Fig.  191. — Lithotomy-forceps:    single  curved. 

denly  stops  flowing  through  the  perineal  opening  within  three  or  four  days, 
and  passes  per  urethram;  this  is  due  to  inflammatory  swelling  and  closure 
of  the  prostatic  wound.  This  soon  subsides,  and  the  urine  again  flows 
through  the  perineum.  Should  the  wound  become  unhealthy,  or  sloughing 
be  threatened,  iodoform,  benzoin,  or  Peruvian  balsam  may  be  applied. 
Should  it  heal  tardily,  it  must  be  stimulated  with  silver  nitrate.  Fistulas 
are  rarely  left  after  closure  of  the  wound.  When  they  do  form  they  require 
caustics,  iodin,  or  the  actual  cautery  to  stimulate  the  tissues  to  renewed 
healing.  Earely  a  plastic  operation  may  become  necessary.  Should  the 
stone  be  too  large  for  extraction,  there  are  two  methods  of  dealing  with  it, 
viz.:  bilateral  incision  and  crushing.  In  the  light  of  our  present  knowl- 
edge of  lithotrity,  the  latter  plan  should  be  selected.  The  fragments  may 
be  scooped  out,  or  crushed  very  finely  and  evacuated  by  the  wound  via  a 
tube,  in  very  much  the  same  manner  as  in  the  ordinary  operation  of  lithol- 
apaxy. 

Dangers  of  Perineal  Lithotomy. — -The  dangers  of  perineal  lithotomy 
are  several,  hemorrhage  being  naturally  the  first  to  be  considered.  Hemor- 
rhage from  the  superficial  perineal  vessels  is  rarely  important,  but,  should 


820  TEINAET    CALCULUS. 

the  internal  pudic  or  artery  of  the  bulb  be  wounded,  serious  consequences 
may  ensue.  Earely,  indeed,  can  these  vessels  be  ligated,  on  account  of 
their  depth;  hence  we  are  compelled  to  resort  to  pressure  to  control  the 
bleeding.  This  may  usually  be  accomplished  by  plugging  the  wound  tightly 
about  the  perineal  tube,  a  gauze  "petticoat"  enabling  us  to  do  this  with 
some  facility.  Styptic  cotton  or  ordinar}'  lint  may  be  used,  but  the  best 
substance  is  dentists'  spunk,  which  spongy  material  swells  to  a  moderate 
degree,  thus  enhancing  pressure.  An  inflated  condom  is  sometimes  suc- 
cessful. Failing  in  these  measures,  relays  of  assistants  should  control  the 
bleeding  b}'  pressure  with  the  aseptized  fingers  in  the  wound;  it  being 
necessary  to  persist  in  this  for  some  hours.  Erichsen  indorses  this  pro- 
cedure very  highly.  Troublesome  hemorrhage  of  this  kind  is  not  likely  to 
occur  if  the  operation  be  properly  performed,  unless,  as  is  unfortunately 
sometimes  the  case,  there  is  an  anomalous  distribution  of  the  arteries. 

Serious  venous  hemorrhage  occasionally  occurs.  The  veins  of  the  pros- 
tate are  sometimes  dilated  and  varicose,  3'ielding  considerable  blood.  This 
condition  is  usualh'  found  in  long-standing  prostatic  disease.  Plugging 
with  st3'ptic  lint  or  cotton  is  very  efficacious  in  these  cases.  Careful  at- 
tention is  necessary  to  avoid  hemorrhage  into  the  bladder.  Concealed 
vesical  hemorrhage  may  be  very  serious,  and  yet  so  insidious  as  to  fail  to 
attract  attention  until  great  loss  of  blood  has  occurred.  It  bears  a  close 
resemblance  in  this  respect  to  certain  cases  of  post-partum  hemorrhage. 
Obstinate  oozing  is  usually  controllable  by  hot  water.  Packing  with  lint 
saturated  with  20-per-cent.  antipyrin  solution  is  often  efficacious.  Turpen- 
tine is  sometimes  of  service  used  in  the  same  manner.  Suprapubic  section 
and  through-and-through  packing  may  be  necessary. 

Several  other  accidents  that  may  occur  in  lithotomy  deserve  mention. 
A  careless  operator  may  miss  the  prostate  altogether,  or  thrust  his  knife 
so  freely  through  the  prostate,  instead  of  carefully  following  the  staff,  that 
the  base  of  the  bladder  is  opened  up.  Pelvic  inflammation  (septic  cellulitis) 
and  urinary  extravasation  with  a  fatal  issue  are  the  usual  sequences  of  this 
blunder. 

The  rectum  is  liable  to  injury,  and  such  an  accident  may  be  followed 
by  recto-vesical  fistula:  a  very  embarrassing  result  indeed.  Slight  rectal 
wounds,  however,  may  granulate  nicely  along  with  the  perineal  and  pro- 
static wound. 

Cases  have  been  known  in  which  the  operator  has  thrust  his  knife 
clear  across  the  bladder,  wounding  its  posterior  wall.  This  is  an  inex- 
cusable accident,  but  may  easily  occur,  especially  in  children,  if  the  knife 
be  thrust  too  far,  or  if  the  bladder  does  not  contain  a  moderate  quantity  of 
urine. 

The  neck  of  the  bladder  in  children  may  be  torn  across  and  the  blad- 
der pushed  bodily  up  into  the  pelvis  by  the  surgeon's  exploring  finger.  This 
accident  is  not  likely  to  occur  if  the  deep  incision  be  sufficiently  free.     It 


LITHOTOMY.  831 

may  usually  be  avoided  by  introducing  a  good-sized  director  along  the 
groove  of  the  staff  into  the  wound.  By  separating  the  director  and  the 
staff  with  a  moderate  degree  of  pressure,  the  track  of  the  wound  may  safely 
be  considerably  dilated.  The  staff  may  then  be  withdrawn  and  the  fore- 
finger passed  along  the  director.  It  is  especially  important  in  children  not 
to  withdraw  the  staff  before  either  the  finger  or  a  director  has  been  passed 
into  the  bladder.  The  exploring  finger  should  be  well  lubricated  with  some 
antiseptic  ointment  before  inserting  it  into  the  bladder. 

Geneeal  Considekations  of  the  Moetalitt  Following  Perineal 
Lithotomy.  —  The  fatalities  following  perineal  lithotomy  are  most  often 
due  to  morbid  conditions  that  complicate  vesical  calculus  rather  than  to 
the  intrinsic  severity  of  the  operation  itself.  The  operation  is  quickly  per- 
formed, as  a  rule,  and  in  competent  hands  is  not  attended  by  special  danger, 
the  various  accidents  that  have  been  described  being  very  exceptional.  Peri- 
neal section  performed  under  favorable  circumstances,  as,  for  example,  in 
removing  foreign  bodies  from  the  cavity  of  the  bladder  prior  to  the  occur- 
rence of  secondary  infection  of  that  viscus,  is  very  rarely  followed  by  an 
unfavorable  result.  When,  however,  the  urethra,  bladder,  and  kidneys  are 
affected  by  the  various  pathologic  conditions  incidental  to  prolonged  uri- 
nary obstruction,  irritation,  and  secondary  infection,  the  mortality  is  rela- 
tively considerable,  and  its  rate  increases  pari  passu  with  the  duration  and 
severity  of  the  complicating  and  secondary  conditions.  There  is  a  marked 
difference  in  the  danger  of  wounds  bathed  with  healthy  urine  and  those 
that  are  brought  in  contact  with  the  unhealthy  secretions  that  characterize 
cases  of  pyelocystic  infection.  The  chronic  urinary  toxemia  incidental  to 
renal  derangements  must  also  be  taken  into  consideration.  The  system  is 
ill  fitted  to  withstand  the  shock  that  necessarily  attends  all  operations  of 
gravity,  its  severity  varying  with  the  nervous  constitution  and  character- 
istic susceptibility  of  the  individual.  Again,  the  effect  of  this  shock  upon 
the  already-damaged  kidney  is  sometimes  productive  of  acute  uremia  and 
death.  This  condition  has  been  sufficiently  expatiated  upon  in  connection 
with  the  subject  of  urine-fever.  The  relatively  favorable  average  results 
of  perineal  lithotomy  in  children  may  be  ascribed  to  the  fact  fbat  in  them 
the  genito-urinary  apparatus  is  usually  comparatively  healthy.  This  rela- 
tively greater  local  resistance  offsets  the  inferior  general  resistancy  of  ex- 
tremely young  subjects  as  compared  with  the  adult  with  respect  to  opera- 
tions. It  will,  of  course,  be  understood  that  there  are  certain  cases  in 
young  and  middle-aged  adults  in  which  the  bladder  is  healthy  and  the 
prognosis  consequently  good,  providing  the  kidneys  are  sound.  The  con- 
trast between  young  children  and  adults  is  only  fair  as  respects  advanced 
cases  in  subjects  well  along  in  years,  and  those  cases  in  relatively  young 
adults  in  which  infection  and  renal  disturbance — one  or  both — have  oc- 
curred early. 

Causes  of  Death  Inciderdal  to  Lithotomy. — In  a  general  way,  the  deaths 


832  UEINAET    CALCULUS. 

following  lithotomy  are  due  to  one  or  more  of  the  following  causes,  viz.: 
(1)  shock;  (2)  hemorrhage;  (3)  uremia;  (4)  septemia;  (5)  septic  cystitis;  (6) 
diffuse  pelvic  cellulitis,  with  or  without  urinary  extravasation  or  gangrene 
of  the  cellular  tissue;    (7)  general  peritonitis. 

One  of  the  most  frequent  causes  of  death  is  the  action  of  the  anesthetic 
upon  the  kidneys.  Acute  nephritis,  or  at  least  acute  renal  hyperemia  from 
this  cause,  may  occur  immediately,  or  it  may  he  delayed  for  some  days,  or 
perhajDS  two  or  three  weeks.  IsTephritis  ex  vacuo  occurs  in  some  cases  of 
removal  of  a  very  large  stone  that  impinges  upon  the  vesical  neck  or  ureters 
in  such  a  manner  as  to  produce  marked  backward  strain  upon  the  kidney. 
The  same  holds  good  in  cases  in  which  a  small  stone  is  forced  against  the 
vesical  neck  during  micturition.  In  some  instances  uremia  is  due  to  light- 
ing up  of  an  acute  infectious  inflammation  of  the  vesical  mucous  membrane 
that  extends  upward  along  the  ureter  to  the  pelvis  of  the  kidney,  producing 
either  acute  pyelitis  or  pyelonephritis,  or  an  acute  exacerbation  of  already 
existing  pyelonephritis. 

Some  of  the  untoward  results  Just  enumerated  are  due  to  accidents 
occurring  during  the  performance  of  the  operation.  Most  of  them,  how- 
ever, as  already  stated,  are  due  to  unavoidable  local  or  general  conditions 
complicating  and,  as  a  rule,  secondary  to  the  stone.  Urine-fever  in  its 
various  phases  covers  quite  a  projoortion  of  the  fatal  cases  of  lithotomy  and 
is  of  especial  importance  with  relation  to  the  pre-existence  of  what  the 
author  has  ventured  to  designate  chronic  urinary  fever. 

MEDIAN"    PEKINEAL    SECTION. 

The  median  section  for  stone  in  the  bladder  was  in  vogue  long  before 
Cheselden's  time,  and  is  said  to  have  been  the  operation  most  often  prac- 
ticed by  the  monks  in  those  dark  and  barbarous  days  when  the  art  of  sur- 
gery was  held  to  be  more  or  less  disreputable,  and  none  but  monks  were 
permitted  to  "cut  for  the  stone."  As  already  stated,  the  operation  has  been 
attributed  to  Marianus  Sanctus  de  Barletta,  who  described  the  method  in 
1543.  Wliether  justly  attributable  to  this  ancient  surgeon  or  not,  his 
name  has  probably  been  immortalized  by  his  connection  with  it.  It  has 
come  down  to  the  latter-day  surgeon  as  the  Marian,  or  Mariani's  operation. 
The  operation  at  present  in  vogue  is  the  modification  of  the  old  Marian 
operation  suggested  by  Allarton,  which  is  a  great  improvement  upon  its 
ancient  predecessor.  With  Marianus  the  principal  object  seems  to  have 
been  to  extract  the  stone  in  a  manner  involving  a  maximum  degree  of  dila- 
tion with  a  minimum  amount  of  cutting. 

To  the  mind  of  Marianus  dilation  was  apparently  synonymous  with 
tearing,  judging  from  the  fact  that  he  devised  dilators  the  function  of  which 
was  evidently  to  tear  the  prostate  in  a  most  unsurgical  and  reckless  fashion. 
It  was  this  fallacious  and  dangerous  flaw  in  the  technic  of  the  operation  as 
originally  devised  that  caused  it  to  fall  into  desuetude,  the  median  being 


LITHOTOMY.  823 

finally  almost  entirely  supplanted  by  the  lateral  operation.  The  advan- 
tages of  the  lateral  section  over  the  old  method  of  median  lithotomy  were  so 
evident  that  it  is  surprising  that  surgeons  should  have  failed  to  recognize 
the  danger  of  mechanic  laceration  of  the  prostate  long  before  the  lateral 
operation  was  perfected  by  Cheselden. 

Opeeation. — The  improved  median  lithotomy  is  performed  in  the  fol- 
lowing manner:  The  patient  having  been  placed  in  the  orthodox  lithotomy 
position,  a  staff  grooved  upon  its  convex  surface  is  introduced  into  the 
bladder  and  held  steadily  in  position  by  an  assistant.  The  left  forefinger 
is  next  introduced  into  the  rectum  to  determine  the  position  of  the  apex 
of  the  prostate  and  to  act  as  a  guide  to  the  knife,  thus  protecting  the  rectum. 
A  straight  stiff-backed  bistoury  is  now  entered  in  the  raphe  half  an  inch 
above  the  -anal  margin,  and  pushed  directly  forward  to  the  groove  of  the 
staff  at  the  apex  of  the  prostate,  thus  opening  up  the  membranous  urethra. 
As  the  knife  is  withdrawn  it  is  made  to  cut  upward  to  a  slight  extent,  thus 
opening  the  membranous  urethra  more  freely  and  enlarging  the  wound  in  the 
skin  and  cellular  tissue.  A  probe  or  grooved  director  is  now  pushed  along 
the  groove  of  the  staff  into  the  bladder,  and  the  staff  withdrawn;  after 
which  the  finger — carefully  cleansed  and  made  aseptic — is  made  to  enter 
the  bladder  by  dilating  the  prostate  with  a  slightly  boring  movement. 
The  subsequent  steps  of  the  operation  are  the  same  as  in  lateral  section, 
but  greater  care  must  be  taken  in  withdrawing  the  stone,  else  serious  lacer- 
ation of  the  prostate  and  the  surrounding  tissues  may  occur!  A  rectangular 
staff  has  been  suggested  in  lieu  of  the  ordinary  curved  instrument,  and  is 
claimed  to  be  much  more  convenient,  inasmuch  as  the  angle  of  the  staff 
when  in  position  corresponds  with  the  apex  of  the  prostate,  and  it  is  almost 
impossible  to  miss  it.  A  rectangular  grooved  guide  set  in  a  stout  handle 
is  safer  than  a  probe  or  ordinary  director  for  the  guidance  of  the  finger  in 
dilating  the  prostate,  as  there  is  less  liability  of  pushing  the  neck  of  the 
bladder  before  the  finger. 

The  median  operation  is  not  so  generally  applicable  as  the  lateral,  but 
is  simpler  and  safer  where  practicable.  It  can  only  be  used  for  small  stones 
— either  single  or  multiple.  Stones  larger  than  one  inch  in  diameter  cannot 
safely  be  removed  by  it,  and,  as  such  stones  are  usually  reserved  for  lithola- 
paxy,  the  scope  of  the  operation  is  necessarily  limited.  The  indications  for 
the  median  section  as  given  by  Erichsen^  are:  (1)  foreign  bodies;  (2)  stones 
of  one  inch  or  less  in  diameter  in  which  the  bladder  is  too  irritable  for 
lithotrity;  (3)  small  stones  behind  an  enlarged  prostate;  (4)  detritus  remain- 
ing after  incomplete  lithotrity;  (5)  in  combination  with  lithotrity  in  stones 
too  large  for  simple  lithotrity,  and  which  do  not  offer  a  favorable  prospect 
for  the  lateral  operation;  (6)  in  anemic  patients  in  whom  the  small  amount 
of  blood  lost  in  the  median  section  renders  it  the  preferable  operation. 


'Science  and  Art  of  Surgery." 


824  UEINAKT    CALCULUS. 

These  indications  as  presented  some  years  since  by  a  world-wide  sur- 
gical celebrity  in  themselves  demonstrate  that  the  median  section  for  stone 
is  something  of  a  surgical  superfin.ity.  Most  of  the  indications  given  can 
be  better  met  by  suprapubic  section  or  litholapaxy.  The  application  of 
median  section  for  stone  should  be  limited  to  young  adults  with  small  stones 
and  very  irritable,  but  otherwise  fairly  healthy,  bladders.  In  such  cases 
the  involved  dilation  of  the  vesical  neck  is  highly  beneficial,  aside  from 
the  extraction  of  the  stone.  In  foreign  bodies  and  very  small  stones  median 
section  will  doubtless  always  have  a  field  of  usefulness,  although  suprapubic 
section  may  often  be  preferred.  If  litholapaxy  be  properly  performed, 
lithotomy  will  rarely  be  necessary  for  the  removal  of  fragments.  Stones  too 
large  for  litholapaxy  had  best  be  removed  by  suprapubic  .section,  although 
Eeginald  Harrison  has  recently  revived  Dolbeau's  operation  of  perineal 
lithotrity.  Litholapaxy  has  practically  done  away  with  all  discussions  as  to 
the  relative  merits  of  different  cutting  operations  in  anemic  patients. 

In  comparing  the  advantages  of  the  median  and  lateral  operations 
nearly  all  surgeons  of  experience  yield  the  preference  to  lateral  lithotomy, 
under  the  age  of  puberty,  and  this  is  certainly  wise,  considering  the  statis- 
tics of  lateral  section. 

The  hilateral  section  of  Dupuytren  and  the  medio-hilateral  section  of 
Civiale  are  merely  modifications  of  the  Cheselden  and  Marian  operations, 
and  have  never  become  popular.  It  is  well,  however,  for  the  surgeon  to 
familiarize  himself  with  them  as  described  in  some  of  the  older  elaborate 
treatises  upon  operative  surgery.  As  in  all  other  surgical  procedures;- 
familiarity  with  all  the  various  operations  for  stone  tends  to  liberalize  the 
operator,  and  renders  him  more  capable  of  adapting  himself  to  unexpected 
circumstances  arising  in  the  course  of  operations. 

SUPEAPUBIC    LITHOTOMY. 

The  high  operation  for  stone  is  an  illustration  of  the  mutability  of 
surgical  fashion.  The  operation  was  introduced  about  the  middle  of  the 
sixteenth  century  by  Pierre  Franco,  but  fell  into  disuse  and  was  known 
chiefiy  traditionally  until  quite  recently,  when  it  was  revived,  mainly 
through  the  efforts  of  Petersen,  whose  modification  has  made  the  method 
quite  popular.  Considering  the  great  strides  that  have  been  made  in  ab- 
dominal surgery,  it  is  not  surprising  that  the  simplest  and  most  direct  of  all 
operations  for  vesical  calculus  should  become  a  recognized  and  safe  oper- 
ation. The  objections  that  were  formerly  advanced  against  the  operation 
do  not  hold  good  at  the  present  day.  Modern  antiseptic  and  aseptic  surgery 
has  modified  the  prevailing  ideas  regarding  suprapubic  lithotomy  quite  as 
markedly  as  other  operations. 

The  only  unfortunate  circumstance  in  the  revival  of  the  suprapubic 
operation  is  the  fact  that  the  neglect  of  the  method  exhibited  in  past  years 


LITHOTOMY.  825 

has  been  replaced  in  our  own  generation  by  overenthnsiasm.  So  reckless 
has  this  enthusiasm  become  that  some  of  our  surgeons  propose  the  high 
operation  as  a  matter  of  routine,  irrespective  of  the  size  of  the  stone  or  the 
condition  of  the  patient.  When  we  consider  the  small  mortality-rate  at- 
tendant upon  litholapaxy  and  lateral  lithotomy  in  young  subjects^  it  is 
hardly  fair,  as  j^et,  to  ask  that  we  substitute  for  them  the  high  operation 
in  all  cases  of  stone.  It  should  be  noted  that  in  children  the  mortality  has 
been  12  per  cent.,  which  record  will  doubtless  be  improved  upon  ere  long. 

In  some  severe  cases  suprapubic  section,  if  properly  performed,  affords 
the  best  chance  of  recovery.  Cases  of  serious  kidney  complication  where  the 
patient  insists  upon  operation,  very  large  stones  with  severe  cystic  inflam- 
mation, tumors  with  or  without  stone,  foreign  bodies  in  the  bladder,  and 
insacculated  stone  are  best. suited  to  the  high  operation  in  both  male  and 
female  subjects.  With  many  surgeons  the  favorite  operation  for  foreign 
bodies  will,  however,  probably  always  be  the  median  section  on  account  of 
its  simplicity  and  safety.  Very  large  stones — i.e.,  those  of  a  diameter  of 
one  inch  and  a  half  or  upward,  stones  too  hard  for  crushing,  and  stones 
with  known  uncrushable  nuclei,  or  nuclei  that  cannot  safely  be  crushed — 
should  usually  be  operated  by  the  high  method.  Stones  may  be  successfully 
removed  in  this  way  in  cases  in  which  the  lateral  operation  would  probably 
yield  a  fatal  result.  The  dangers  of  lateral  lithotomy  increase  rapidly  with 
the  size  of  the  stone,  which  is  not  so  true  of  the  suprapubic  operation, 
although  on  account  of  associated  conditions  the  prospect  may  not  be  quite 
so  good  in  large  as  in  small  stones.  Interference  with  the  urethra,  prostate, 
and  vesical  neck  involved  in  lateral  section  is  much  more  likely  to  produce 
some  form  of  urine-fever  than  suprapubic  section,  and  this  is  especially  true 
where  secondary  involvement  of  the  kidneys  is  pronounced.  The  explana- 
tion for  this  lies  in  the  extreme  sensitiveness  and  close  association  of  these 
parts  with  the  sympathetic  system,  as  compared  with  the  structures  in- 
volved in  the  high  operation. 

Opekation. — Petersen's  operation  is  performed  as  follows:  The  patient 
is  prepared  as  for  ordinary  lithotomy.  After  thorough  scrubbing  the  ab- 
domen is  cleansed  with  a  weak  bichlorid  or  strong  carbolic  solution  as  for 
celiotomy  and  the  hair  is  shaved  off  the  pubes.  Instead  of  the  lithotomy 
position  the  patient  is  placed  upon  his  back.  The  bladder  is  now  washed 
out  with  a  warm  antiseptic  solution  (ac.  carbol.,  ac.  boric,  borax,  or  salic- 
ylate of  soda)  via  a  soft  catheter. 

Petersen's  rectal  bag  (colpeurynter)  is  now  introduced  and  filled  with 
10  or  12  ounces  of  water,  thus  pushing  the  bladder  forward  and  upward. 
Care  is  necessary  in  this  procedure,  as  the  injection  of  an  excess  of  water 
or  too  rapid  filling  of  the  bag  may  rupture  the  rectum — this  has  happened 
to  several  competent  operators.  The  bladder  is  next  filled  with  from  8  to 
12  ounces  of  a  mild  antiseptic  solution,  thus  bringing  the  viscus  upward 
and  forward  still  more  prominently.    Caution  is  also  necessary  at  this  point. 


826  UEINAEY    CALCULUS. 

for  the  bladder — especially  if  much  diseased — may  be  ruptured  by  over- 
distension. 

An  incision  is  now  made  in  the  median  line  just  above  the  symphysis 
pubis;  this  should  begin  about  three  to  three  and  one-half  inches  above, 
and  terminate  at,  the  symphysis,  involving  the  skin  and  cellular  tissue 
down  to  the  recti  muscles;  its  length  necessarily  varies  a  little  according 
to  the  corpulency  of  the  subject.  The  deep  incision  should  next  be  made; 
if  practicable,  exactly  between  the  recti  muscles;  but  there  should  be  as 
little  tearing  and  bruising  of  the  tissues  as  possible.  After  the  muscles 
have  been  cut  through  the  transversalis  fascia  is  exposed  and  should  be 
carefully  incised  upon  a  director,  beginning  at  the  lower  angle  of  the  wound, 
at  which  point  it  is  impossible  to  pick  up  the  peritoneum  in  the  majority 
of  cases.  Beneath  this  fascia  in  the  prevesical  space — cavity  of  Retzius — 
is  a  quantity  of  fat  that  should  be  pushed  or  rolled  upward  out  of  the  way, 
— enroulement, — as  practiced  by  Guyon.  Should  the  peritoneum  be  ac- 
cidentally cut,  the  wound  is  immediately  sewed  with  fine  catgut  and  the 
operation  proceeded  with. 

The  bladder  is  now  brought  plainly  in  view.  Curved  needles  threaded 
with  heavy  silk  are  next  passed  through  the  bladder-walls,  one  upon  each 
side  and  parallel  with  the  line  of  incision,  and  brought  out  so  as  to  leave 
a  long  double  thread;  the  ends  of  these  threads  are  tied  so  that  the  blad- 
der may  be  held  against  the  edges  of  the  woimd  by  the  loops  in  the  hands 
of  assistants.  A  free  vertical  incision  is  next  made  into  the  bladder  and  its 
interior  thoroughly  examined  both  by  the  eye  and  finger.  Should  the  parts 
be  seen  with  diificulty,  the  Trendelenburg  position  will  draw  the  bladder 
into  plainer  view  by  the  suction-force  of  the  receding  abdominal  viscera. 
The  stone  having  been  removed  by  fingers  or  forceps,  the  bladder  is  once 
more  washed  out,  a  catheter  introduced,  and  the  bladder  sutured,  care  being 
taken  to  suture  through  the  muscular  walls  only,  and  not  through  the  mu- 
cous membrane.  A  small  quantity  of  gauze  is  left  just  above  the  pelvis  to 
drain  the  prevesical  space,  and  the  external  wound  sutured  as  in  ordinary 
abdominal  section. 

It  is  recommended  by  some  that  a  suprapubic  drainage-tube  be  left  in 
the  bladder;  but  this  is  unnecessary  where  the  bladder  is  sutured.  When- 
ever the  vesical  wound  is  closed,  a  drainage-tube  should  usually  be  inserted 
through  a  toutonniere  in  the  perineum,  though  a  soft  catheter  per  urethram 
may  suffice. 

Experience  has  led  the  author  to  modify  the  Petersen  method  some- 
what. The  rectal  bag  is  unnecessary  and  also  dangerous.  The  bladder  is 
always  accessible  unless  contractured  and  hardened,  in  which  event  the 
rectal  bag  is  of  but  little  assistance  anyway.  The  fingers  of  an  assistant 
in  the  rectum  fulfill  the  indications  much  better  than  the  rectal  bag.  With 
the  Guyon  method  of  enroulement,  the  peritoneum  is  rarely  seen.  Should 
it  be  cut,  it  should  be  stitched,  and  the  wound  packed  for  two  or  three  days 


LITHOTOMY.  827 

before  entering  the  bladder.  This  operation  in  two  stages^ — first  employed 
in  France — should  be  the  operation  of  election  in  feeble  patients  with  septic 
bladders.  The  danger  of  infection  is  made  practically  nil  by  it.  Where 
the  section  a  deux  temps  is  deliberately  chosen  the  bladder  should  be  ex- 
posed over  as  wide  an  area  as  possible,  and  the  packing  allowed  to  remain 
for  five  days.  In  very  large  stones,  in  tumors,  and  where  the  peritoneum 
is  low  down  or  the  bladder  contracted,  the  author  has  practiced  the  follow- 
ing method:  The  bladder  is  exposed  in  the  usual  manner,  and  the  peri- 
toneum deliberately  incised  for  as  great  an  extent  as  deemed  necessary. 
The  bladder  is  drawn  out  of  the  incision  to  the  required  extent  and  the 
peritoneum  stitched  around  it,  temporary  retention  sutures  being  placed  in 
the  sides  of  the  bladder  and  edges  of  the  abdominal  wound.  The  bladder  is 
packed  about  with  iodoform  gauze  and  the  usual  dressings  applied.  On  the 
fifth  day  the  operation  may  be'  proceeded  with.  There  is  now  plenty  of 
room,  a  large  surface  of  the  bladder  being  uncovered  by  peritoneum.  Stitch- 
ing the  bladder  is  thus  made  a  very  simple  matter.  In  the  ordinary  operation 
a  deux  temps  both  the  preliminary  and  secondary  incisions  may  be  done 
under  Schleich's  method,  thus  obviating  the  dangers  of  general  anesthesia. 
As  already  noted,  the  Trendelenburg  posture  greatly  facilitates  all  operations 
upon  the  bladder,  and  especially  intravesical  operations  upon  the  prostate. 
In  extremely  septic  bladders  through-and-through  drainage  is  best.  The 
author  does  not  advocate  vesical  suture  save  in  exceptional  cases  where  in- 
fection is  not  to  be  apprehended.  Where  suture  is  performed,  the  wound 
leading  down  to  the  line  of  suture  should  be  carefully  packed,  secondary 
silk-worm-gut  sutures  being  utilized  for  the  closure  of  the  external  wound 
as  soon  as  it  is  deemed  safe  to  do  so:  i.e.,  in  four  or  five  days.  Even  then  it 
is  wise  to  leave  a  bit  of  gauze  drainage  in  the  lower  angle  of  the  wound, 
leading  down  to  the  cavity  of  Eetzius. 

Observations  made  during  experiments  on  intestinal  suture  in  1881, 
showing  the  ready  repair  of  accidental  wounds  of  the  bladder,  led  Eydygier, 
of  Krakow,  to  the  idea  that  the  tendency  to  adhesion  of  the  peritoneum 
could  be  utilized  in  cystotomy.  To  prove  this  he  made  a  series  of  experi- 
ments on  dogs,  and,  encouraged  by  the  results,  operated  on  a  boy  thirteen 
years  of  age.     Eydygier's  method  of  operating  is,  briefly,  as  follows: — 

The  patient  is  prepared  as  for  laparotomy,  a  catheter  is  passed  into  the  bla(ider, 
and  the  latter  is  washed  out  with  a  warm  solution  of  boric  or  salicylic  acid,  and 
then  partly  filled  with  the  same  solution.  A  section  is  made  on  the  linea  alba,  as 
usual.  After  letting  out  the  solution  by  means  of  a  catheter,  the  bladder  is  drawn 
out  by  a  silk  noose,  and  iodoform  gauze  is  solidly  packed  in  between  the  bladder  and 
the  edge  of  the  wound.  An  incision  one  and  a  half  inches  long  is  made  in  the  bladder, 
and  the  finger  is  inserted  and  along  it  the  forceps.  The  bladder  is  again  washed  out 
by  the  catheter  with  the  above  solution,  which  may  overflow  the  wound  of  the  bladder 
without  entering  the  cavity  of  the  abdomen.  Eydygier  recommends  applying  the 
furrier's  suture  according  to  Czerny's  method.  This  suture  has  this  advantage:  that 
the  more  the  bladder  distends,  the  more  the  suture  tightens.     It  is  necessary  to  keep 


828 


UEIXAEY    CALCULUS. 


the  catheter  in  the  bladder  for  eight  to  twelve  days.  Rydygier's  method  can  par- 
ticularly be  applied  to  the  entire  removal  of  tumors  of  the  bladder,  and  it  may  also 
be  of  use  in  wounds  of  this  viscus.^ 

The  after-treatment  of  suprapubic  cystotomy  consists  of  ordinary  anti- 
septic dressings,  changed  as  required,  siphon-drainage  with  daily  vesical 
irrigation,  and  removal  and  cleansing  of  the  catheter  or  drainage-tube.  At 
the  end  of  a  week  or  ten  days  it  is  usually  safe  to  allow  the  perineal  tube  or 
catheter  to  remain  out  for  forty-eight  hours.  If  no  urine  escapes  through 
the  abdominal  wound  at  the  end  of  that  time,  the  drainage-tube  may  be 
dispensed  with  permanently.  The  patient  should  be  instructed  to  urinate 
at  short  intervals  for  a  few  weeks,  to  prevent  undue  tension  upon  the  ves- 
ical cicatrix.  The  bladder  should  be  washed  out  daily  with  a  weak  borated 
or  carbolized  solution  for  some  time. 

In  occasional  cases  either  a  truss  or  a  radical  operation  will  be  neces- 
sary sooner  or  later  on  account  of  hernial  protrusion  consequent  upon  yield- 
ing of  the  cicatrix.  . 


Fig.   192. — Irregular  calculi  removed  by  suprapubic  section  from  case  of  X. 
Uric-acid  nuclei  Avith  phosphatic  laminae.     (Author's  case.) 

Occasional  cases  will  be  met  with  in  which  removal  of  large  stones 
suprapubically  is  followed  by  a  fatal  result  because  of  certain  conditions  in 
which  the  presence  of  the  stone  is  apparently  necessary  to  the  preservation 
of  the  integrity  of  the  vesical  wall.  The  pressure  of  the  stone,  while  dis- 
astrous, apparently  prevents  sloughing  of  the  portion  of  the  bladder  on 
which  it  rests.  The  following  case  would  appear  to  be  an  illustration  of 
this : — 

Case. — X,  a  man,  65  years  of  age,  consulted  the  author  regarding  vesical 
irritation  of  nearly  ten  years'  duration.  Exploration  revealed  stone  of  large  size, 
whether  one  or  more  could  not  be  determined  because  of  the  large  size  of  the  cal- 
culous mass  and  the  contracted  state  of  the  bladder.  Suprapubic  section  was  per- 
formed and  two  large  stones  weighing  1500  grains  (Fig.  192)  removed  with  some 
difficulty,  but  without  injury  to  the  incised  portion  of  the  vesical  wall,  save  that 


^Przeglad  Lekarski,  Nos.  6  and  7,  1888. 


I 


LITHOTOMY.  829 

incidental  to  the  incision  itself.  A  lithotomy-scoop  and  the  fingers  only  were  used 
in  extracting  the  calculi.  The  bladder  was  adherent  to  the  edges  of  the  stones  where 
they  came  in  apposition.  The  peritoneum  was  not  seen  during  the  operation.  The 
patient  died  of  septic  peritonitis  on  the  fourth  day  after  operation.  On  the  second 
day  the  vesico-rectal  septum  sloughed,  and  enemata  passed  freely  from  the  rectum 
into  the  bladder.     No  autopsy  could  be  secured. 

In  the  foregoing  case  sloughing  of  the  yesical  wall  was  probably  due  to 
the  sudden  removal  of  the  pressure  of  the  calculi  and  incidental  acute  sepsis, 
the  phenomena  being  similar  to  those  occurring  after  the  sudden  evacuation 
of  retained  urine  in  old  septic  bladders.  The  peritonitis  was  due,  in  the 
author's  opinion,  to  slight  laceration  of  the  degenerated  and  friable  vesical 
wall,  with  its  peritoneal  investment,  by  the  tearing  away  of  the  adherent 
calculi.  Adhesion  of  calculi  to  the  vesical  walls  is  certainly  a  very  rare  con- 
dition, but  one  that  undoubtedly  existed  in  this  case,  as  shown  both  by  the 
conditions  found  during  removal  and  the  appearance  of  the  calculi  after 
removal. 


CHAPTEK  XXXV. 

NEUROSES  OF  THE  BLADDER. 

Vesical  Hypeeesthesia;    Vesical  Neuealgia;    Vesical  Atony  and 
Paealysis;  Hysteeia  of  the  Bladdee;  Incontinence  of  Ueine. 

vesical  hypeeesthesia. 

Uxdee  the  term  hyperesthesia  of  the  bladder  the  author  desires  to 
call  attention  to  an  affection  that  is  not  generally  recognized,  but  which 
is  of  the  greatest  importance,  not  only  as  a  morbid  condition  per  se,  but 
as  a  complication,  or  perhaps  sequel,  of  other  vesical  diseases.  Hyperesthe- 
sia of  the  vesical  mucous  membrane  is  necessarily  a  feature  of  acute  inflam- 
mation and  chronic  obstructive  diseases  of  the  genito-urinary  tract,  but 
under  favorable  circumstances  it  constitutes  merely  a  subordinate  element, 
its  management  being  that  of  the  organic  disease.  It  is  only  when  it  exists 
independently  of  organic  disease,  or  is  greatly  disproportionate  to  the  or- 
ganic changes  present,  that  it  becomes  worthy  of  special  nomenclature  and 
consideration. 

Vesical  hyperesthesia  has  been  described  under  the  various  terms  of 
"cystitis  without  catarrh,"  "irritable  bladder,"  and  "neuralgia  of  the  ves- 
ical neck."  To  each  of  these  terms  the  author  takes  exception.  Cystitis 
without  catarrh  is  a  pathologic  paradox,  and,  as  such,  incomprehensible. 
Irritability  of  the  bladder  is  a  better  term,  but  implies  only  intolerance  of 
the  vesical  mucous  membrane  for  the  contents  of  the  bladder,  which  con- 
tents may  be  normal  or  pathologic.  Xeuralgia  of  the  vesical  neck  is  a 
term  that  should  be  reserved  for  another  condition.  Neuralgia,  moreover, 
does  not  accurately  describe  conditions  of  hyperesthesia. 

The  morbid  condition  existing  in  vesical  hyperesthesia  is  simply  an 
exaggeration  of  the  normal  physiologic  sensibility  of  the  organ.  The  proper 
performance  of  the  vesical  function  depends  in  great  measure  upon  the 
sensibility  of  the  mucous  membrane.  When  in  its  normal  condition  the 
viscus  will  hold  a  considerable  quantity  of  urine,  the  amount  varying  in 
different  individuals;  when,  however,  the  organ  is  moderately  distended 
by  its  contents,  a  sense  of  fullness,  and  perhaps  pain,  with  a  more  or  less 
urgent  desire  to  urinate,  are  experienced.  When  this  normal  sensibility  is 
decreased,  overdistension  is  likely  to  occur;  when  it  is  increased,  the  blad- 
der becomes  proportionately  intolerant  of  its  contents,  necessitating  fre- 
quent micturition. 

It  is  probable  that  the  principal  seat  of  the  desire  to  iirinate  is  the 
mucous  membrane  lining  the  true  vesical  neck, — i.e.,  the  deep  urethra; 
hence  a  relatively  greater  degree  of  hyperesthesia  from  morbid  conditions 
(830) 


VESICAL    HYPERESTHESIA.  831 

of  this  portion  of  the  yesical  lining  than  in  those  chiefly  involving  the 
superior  portion  of  the  bladder  is  to  be  expected. 

As  might  be  supposed,  the  muscular  structure  of  the  bladder  eventu- 
ally participates  in  the  abnormal  increase  of  sensibility,  and  consequently 
exhibits  a  tendency  to  spasmodic  contraction.  This  spasmodic  contraction 
is  the  principal  cause  of  the  severe  pain  experienced  in  bladder  disease. 

From  what  has  already  been  said,  the  clinical  division  of  vesical 
hyperesthesia  into  general  and  local  will  be  readily  appreciated.  Cases 
often  occur  in  which  moderate  distension  of  the  bladder  will  immediately 
produce  pain  and  a  strong  desire  to  urinate,  but  in  which  the  presence  of 
a  small  amou^nt  of  urine  is  well  tolerated.  These  cases  are  explicable  only 
upon  the  supposition  that  the  vesical  neck  is  not  involved  to  any  great 
extent.  More  frequently,  however,  cases  are  met  with  in  which  the  desire 
to  urinate  is  almost  constant,  pain  being  slight  or  absent  because  of  the 
fact  that  the  bladder  is  rarely  allowed  to  become  sufficiently  distended  to 
produce  mechanic  pressure.  These  cases  comprise  those  that  several  writers 
have  termed  neuralgia  of  the  vesical  neck,  and  involve  the  prostatic  ure- 
thra— the  true  vesical  neck — as  well  as  the  false  vesical  neck. 

A  certain  degree  of  chronic  inflammation  exists  in  a  large  number  of 
these  cases,  and  it  is  safe  to  assume  that  in  cases  of  long  standing  the 
frequent  bruising  of  the  parts  about  the  neck  of  the  bladder  caused  by 
frequent  straining  efforts  at  micturition  has  produced  inflammation,  even 
if  it  did  not  primarily  exist. 

Etiology.  —  The  possible  causes  of  vesical  hyperesthesia  are  quite 
numerous.  The  majority  of  cases  result  from  pre-existing  acute  or  chronic 
inflammation.  Frequent  efforts  at  micturition  due  to  inflammation  cause 
the  bladder  to  acquire,  from  sheer  force  of  habit,  intolerance  of  its  contents. 
As  a  result,  the  organic  disease  does  not  subside  completely,  but  becomes 
subordinate  to  the  hyperesthesia;  thus  cystitis,  gonorrhea,  or  prostatitis 
may  constitute  the  exciting  cause  of  chronic  hyperesthesia  of  the  bladder. 

A  neurotic  constitution  underlies  many  cases,  and  under  such  circum- 
stances comparatively  slight  causes  may  disturb  the  nervous  supply  of  the 
bladder.  Associated  with  this  neurotic  constitution,  perverted  sexual  phys- 
iology is  apt  to  constitute  an  important  element  in  etiology.  Such  patients 
will  be  found  to  suffer  either  from  sexual  excess,  or,  what  is  quite  as  harm- 
ful, constant  ungratified  sexual  desire.  Intemperate  habits  of  eating  and 
drinking  are  apt  to  act  injuriously  upon  the  bladder,  by  inducing  an  irri- 
table state  of  the  tissues  in  general,  as  well  as  by  the  production  of  irri- 
tating properties  in  the  urine. 

Oxaluria,  phosphaturia,  and  lithemia  are  often  associated  with  hyper- 
esthesia of  the  bladder.  The  gouty  or  rheumatic  diathesis  is  responsible 
for  many  cases:  a  point  that  has  received  too  little  attention.  The  author 
has  met  with  a  number  of  cases  of  rheumatism  of  the  bladder  with  conse- 
quent hyperesthesia  due  to  exposure  to  cold  and  wet.     It  is  noteworthy 


832  NEUEOSES    OF    THE    BLADDEE. 

that  the  majority  of  cases  are  affected  injuriously  by  atmospheric  changes. 
Some  patients  are  annoyed  mostly  during  the  changeable  weather  of  the 
spring  and  fall^  being  at  other  seasons  quite  free  from  trouble.  Hyper- 
esthesia of  the  bladder  is  occasionally  the  result  of  reflex  nervous  irrita- 
tion, either  from  contiguous  or  more  or  less  remote  pathologic  changes. 
Diseases  of  the  anterior  portion  of  the  urethra,  of  the  rectum  and  anus,  or 
of  the  uterus  and  ovaries  may  constitute  the  source  of  the  reflex  disturb- 
ance. Phimosis,  teething,  and  worms  may  cause  it  in  children.  Eenal 
calculus  or  pyelitis  are  occasionally  reflex  causes. 

Symptoms. — The  symptoms  of  vesical  hyperesthesia  vary  somewhat, 
as  has  been  stated,  according  to  the  general  or  local  character  of  the  mor- 
bid condition.  When  it  is  general,  there  is  more  or  less  pain,  and  perhaps 
tenderness,  over  the  hypogastrium  when  the  bladder  becomes  distended 
with  urine.  If,  however,  the  vesical  neck  and  prostatic  sinus  are  chiefly 
involved,  the  bladder  is  so  intolerant  of  urine  that  distension  and  hypo- 
gastric pain  cannot  occur.  There  is  an  almost  constant  desire  to  urinate 
in  cases  of  this  character,  and  in  most  cases  a  sensation  of  impending  dis- 
charge of  urine  during  intervals  between  the  acts  of  micturition.  Irrita- 
tion in  the  prostatic  sinus  sometimes  gives  rise  to  voluptuous  or  tickling 
sensations  in  the  perineum.  The  urine  may  be  highly  concentrated  and 
acid,  neutral,  or  perhaps  phosphatic,  according  to  the  condition  upon  which 
the  hyperesthesia  depends.  There  is  little  or  no  mucus  or  muco-pus  unless 
inflammation  be  a  prominent  factor  in  the  case.  Great  nervous  irritability 
or  depression  are  usual,  hypochondria  being  often  the  most  prominent 
feature,  particularly  if  oxaluria  be  present.  There  are  some  peculiar 
features  in  the  symptomatology  of  vesical  hyperesthesia,  especially  when 
limited  to  the  neck  of  the  organ.  Mental  worry  or  strain  is  apt  to  ag- 
gravate the  condition  or  even  produce  it  primarily.  Overworked  students 
who  have  consulted  the  author  for  this  difficulty  have  laid  particular  stress 
upon  this  feature  of  the  case.  The  sound  of  running  water,  or  the  sight  of 
another  individual  in  the  act  of  urination,  often  occasions  an  almost  un- 
controllable desire  to  empty  the  bladder.  A  physician  of  the  author's  ac- 
quaintance experiences  this  symptom  whenever  a  patient  describes  bladder 
symptoms  to  him.  When  attention  is  diverted,  and  during  sleep,  the  pa- 
tient is  not  annoyed,  as  a  rule,  unless  there  is  actual  cystitis.  Sometimes, 
however,  frequent  nocturnal  micturition  from  vesical  hyperesthesia  will 
continue,  as  a  matter  of  physiologic  habit,  for  a  long  time  after  the  dis- 
appearance of  primary  organic  disease  upon  which  it  originally  depended. 

Teeatment. — The  treatment  of  vesical  hyperesthesia  requires  a  careful 
study  of  its  possible  causes,  for  much  depends  upon  the  prominence  of  in- 
flammatory complications.  Genito-urinary  and  sexual  hygiene  require  at- 
tention in  all  cases.  Morbid  conditions  of  the  urine  require  attention  as  a 
preliminary  to  all  other  means  of  treatment.  When  strongly  acid,  with 
deposits  of  uric  acid  and  urates,  a  milk  diet,  with  alkaline  diuretics,  is 


VESICAL    HYPEEESTHESIA.  833 

required.  In  some  cases,  however,  the  condition  is  either  oxalnria  or  a 
highly-acid  and  concentrated  state  of  the  urine  due  to  malassimilation :  i.e., 
Htheniia.  In  such  cases  the  digestive  and  hepatic  functions  are  perverted, 
and  dihite  nitromuriatic  acid  should  be  substituted  for  the  alkalies.  Col- 
chicum  is  indicated  in  full  doses  if  the  gouty  tendency  be  pronounced. 
The  salts  of  lithia  are  also  ver}''  serviceable.  Some  of  the  various  alkaline 
mineral  waters  should  be  recommended  as  a  constant  beverage.  In  patients 
of  a  neurotic  constitution,  ergot,  gelsemium,  and  the  bromids  are  indicated. 
These  drugs  should  be  combined  with  tonics,  such  as  the  dilute  phosphoric 
acid,  quinin,  iron,  and  strychnia  in  debilitated  patients.  Sexual  hygiene 
demands  attention  in  most  instances.  Marriage  will  often  cure  the  most 
stubborn  cases  of  hyperesthesia  of  the  vesical  neck. 

The  only  local  treatment  required  in  the  majority  of  cases  is  the  pas- 
sage of  the  steel  sound.  This  is  to  be  used  cautiousl}^,  however,  for,  while 
it  is  almost  a  specific  for  cases  of  a  purely  nervous  type,  it  is  apt  to  aggra- 
vate the  difficulty  if  infectious  inflammation  about  the  vesical  neck  exists. 
The  instrumentation,  if  beneficial,  acts  by  squeezing  out  the  blood  from  the 
vesical  neck,  thus  relieving  congestion,  and  by  stretching  the  delicate  nerve- 
filaments  lessens  their  irritability.  When  the  sound  proves  useless  or  detri- 
mental, irrigation  with  mild  warm  lotions  will  give  great  relief.  The  short 
urethral  nozzle  should  be  used,  if  practicable.  Instillations  of  silver  nitrate 
are  of  service  where  infection  exists.  These  should  be  given  in  a  strength 
of  from  2  V2  to  15  grains  to  the  ounce. 

Cold  s|)onge-baths  and  ph3^sical  exercise  in  moderation  are  essential  in 
most  cases. 

Stimulants  and  tobacco  are  apt  to  be  especially  injurious,  and  should 
be  strictly  interdicted. 

Eest  in  bed  and  the  api3lication  of  blisters  to  the  perineum  and  hypo- 
gastrium  are  necessary  in  some  stubborn  cases.  The  application  of  iodin 
to  the  perineum  and  hypogastrium  is  always  admissible.  Opium  is  often 
necessary  where  the  disease  is  troublesome.  It  should  be  given  pref- 
erably in  the  form  of  suppositories  or  the  deodorized  tincture  in  small 
doses,  and  should  be  dispensed  with  after  sudden  exacerbations  of  the  dis- 
ease have  been  controlled.  Hyoscyamus,  cocain,  and  belladonna  are  occa- 
sionally of  service.  The  fluid  extract  of  pichi  has  proved  beneflcial  in  some 
cases.    Cantharides  in  small  doses  is  sometimes  of  benefit.  • 

The  following  formulas  are  among  the  most  reliable  that  the  author 
has  tried  in  vesical  hyperesthesia: — 

IJ  Potass,   citrat §j. 

Infusi  buchu Bviij. 

M.     Sig. :    Bss  quor  die. 

Infusions  of  slippery  elm,  linseed,  or  triticum  repens  may  be  substi- 
tuted for  the  buchu. 


834:  NETJEOSES    OF    THE    BLADDEK. 

IJ  Tr.  canthar m.  Ixxx. 

Potass,  acetat §j . 

Syr.  limonis q.  s.  ad  giv. 

M.     Sig. :    3  every  three  hours. 

IJ  Tf.  opii  deed 3ii  m.  xl. 

Potass,  bicarb 3vi  3  j. 

Syr.  Tolu q.  s.  ad  giv. 

M.     Sig.:    3j  every  three  hours. 

IJ  CodeinEe gr.  iv. 

Ext.  pichi  fld giss. 

Lithii  carb 3iv. 

Syr.  acacise q.  s.  ad  §iv. 

M.     Sig.:    3ij  every  two  hours. 

1$.  Cocain  mur.^ 
Ext.  belladon., 

Morph.   sulph of  each  gr.  ^U. 

Pulv.   camph gr.  1. 

M.     Ft.  rectal  suppos. 

Sig.:  Use  at  bed-time.  Indicated  in  cases  of  vesical  irritation  from  whatever 
cause. 

Ijl  Vini  colch.  sem 3ii  m.  xl. 

Liq.  potass 3ii  m.  xl. 

"Tr.   hyoscyami Bj. 

Kalii  brom. §j. 

Elix.  simpl q.  s.  ad  Biv. 

M.     Sig.:    3ij  in  water  every  four  hours. 

Where  it  is  necessary  to  allay  sexual  irritability,  the  following  com- 
bination "usually  acts  well: — 

I^  Kalii   brom 3iv. 

Ext.  ergotse  fl 3iv. 

Tr.  gelsemii m.  Ixxx. 

Syr.  Tolutani q.  s.  ad  §iv.   . 

M.     Sig.:    3ij  every  three  hours. 

Extreme  dilation  of  the  vesical  neck  is  often  successful  in  curing  cases 
in  which  hyperesthesia  of  this  region  predominates. 

VESICAL   NEUEALGIA. 

True  neuralgia  of  the  bladder  is  infrequent,  and  when  it  occurs  is 
likely  to  be  mistaken  for  other  vesical  diseases.  Where  it  chances  to  be 
associated  with  morbid  conditions  of  the  urine,  it  is  especially  liable  to  be 
mistaken  for  malignant  disease. 

Vesical  neuralgia  may  be  general  or  local,  and  may  or  may  not  be' 
associated  with  hyperesthesia.  Its  causes  are  much  the  same  as  those  of 
the  latter  condition,  gout,  rheumatism,  malaria,  and  cachexias  of  various 


VESICAL   HYPEKESTHESIA   AND   NEURALGIA.  835 

kinds  liaviug  a  very  prominent  place  in  the  etiology  of  different  cases.  It 
may  attend  upon^  or  follow,  inflammatory  diseases  of  the  genito-urinary 
tract. 

The  symptoms  consist  of  pain  of  a  paroxysmal  and  irregular  character. 
This  may  be  intermittent,  or  more  or  less  constant,  and  is  referred  to  the 
hypogastrium  and  perineum.  In  some  cases  it  radiates  to  the  rectum,  ure- 
thra, and  lumbo-ahdominal  region. 

In  simple  and  uncomplicated  cases  there  are  no  symptoms  or  signs 
referable  to  the  urine,  but  in  others  there  are  phenomena  characteristic  of 
the  conditions  with  which  the  neuralgia  is  associated.  In  some  cases  the 
urine  is  perfectly  normal  and  micturition  is  not  abnormally  frequent,  yet 
the  act  is  attended  by  severe  cutting  pains.  The  act  of  ejaculation  is  also 
attended  in  some  cases  by  similar  symptoms.  The  symptomatic  tout  en- 
semble is  quite  suggestive  of  vesical  calculus,  and  some  care  is  necessary  to 
avoid  error  in  diagnosis. 

Treatment. — The  treatment  of  true  neuralgia  of  the  bladder  neces- 
sarily varies,  according  as  the  condition  is  primary,  secondar}^,  or  reflex  in 
character.  Tonics  are  invariably  indicated,  and  in  malarial  cases  depend- 
ence is  to  be  placed  chiefly  upon  quinin.  Arsenic,  phosphorus,  iron,  strych- 
nin, and  the  mineral  acids  are  indicated  in  different  cases.  A  change  of 
climate  may  be  required.  The  local  treatment  is  that  of  the  primary  or- 
ganic disease,  if  such  be  present,  with  the  addition  of  galvanism  in  some 
cases,  particularly  when  the  neuralgia  appears  to  be  independent  of  serious 
structural  disease.  Hot  irrigations  of  the  bladder  and  bowel,  with  anodyne 
fomentations  and  poultices  to  the  hypogastrium,  are  of  service  when  the 
pain  is  very  acute.     Anodyne  suppositories  are  always  useful. 

vesical  hyperesthesia  and  neuralgia  in  women. 

Hyperesthesia  of  the  bladder  in  women  is  quite  common,  and  is  fre- 
quently either  overlooked  or  erroneously  diagnosed  as  cystitis. 

Etiology. — The  causes  are  the  same,  in  a  general  wa}^,  as  those  of  the 
same  condition  in  the  male.  In  addition,  however,  women  are  subject  to 
the  special  causes  of  reflex  tubo-ovarian  and  uterine  irritation  and  pressure 
from  uterine  displacements.  In  some  cases  there  exists  no  special  cause. 
Nearly  all  of  the  severe  cases  of  uterine  displacement  met  with  in  practice 
are  associated  with  vesical  hyperesthesia,  and  this  condition  is  apt  to  be 
localized  chiefly  about  the  vesical  neck.  Oftentimes-  a  certain  degree  of 
actual  inflammation  exists,  and  where  it  is  not  primarily  present  it  is  quite 
apt  to  occur  sooner  or  later  as  a  result  of  the  mechanic  conditions  that 
cause  the  hyperesthesia,  in  conjunction  with  frequent  micturition. 

ISTeuralgia  of  the  bladder  in  women  is  essentially  the  same  as  in  the 
male. 

Treatment. — The  treatment  of  vesical  hyperesthesia  and  neuralgia  in 
women  is  the  same,  in  a  general  way,  as  in  the  male.    Dilation  of  the  neck 


836  XEUEOSES    OF    THE    BLADDEE. 

of  the  bladder  by  short  urethral  sounds  is  usually  effectual.  In  many 
cases  the  relief  obtained  is  really  remarkable.  Uterine  displacements  re- 
quire most  careful  consideration  in  cases  of  this  kind.  In  some  cases  ex- 
treme dilation  of  the  vesical  neck  imder  anesthesia  is  necessary.  This 
radical  measure  rarely  fails. 

VESICAL    ATOXT. 

Atony  of  the  bladder  implies  a  partial  paresis  or  exhaustion  of  mus- 
cular power — a  loss  of  the  normal  muscle-tonus — of  the  vesical  Avails:  i.e., 
of  the  detrusor-uringe  muscle. 

Etiology. — The  cause  of  vesical  atony  may  be  said  to  be,  briefly,  over- 
stretching of  muscular  tissue.  This  overstretching  of  the  vesical  walls  is 
due  either  to  prolonged  acute  retention  of  urine  or  continual  obstruction 
to  its  escape.  Should  either  of  these  conditions  prevail  in  a  debilitated  in- 
dividual, vesical  atony  is  apt  to  supervene  quite  promptly,  for  the  general 
tone  of  the  system  has  much  to  do  with  the  tonicity  of  the  vesical  walls. 
Conditions  of  chronic  debility  and  long-continued  acute  diseases  are,  there- 
fore, apt  to  be  complicated  by  atony  of  the  bladder.  Eetention  of  urine, 
for  even  a  short  time,  is  always  followed  by  a  greater  or  less  degree  of 
atony.  It  is  quite  apt  to  complicate  organic  stricture,  and  often  persists 
after  the  obstruction  has  been  removed.  This  should  be  remembered,  as 
patients  are  often  dissatisfied  with  the  condition  of  their  urinary  organs 
after  the  cure  of  stricture,  and  an  explanation  of  the  lack  of  power  experi- 
enced in  micturition  should  be  given  them.  Atony  of  the  bladder  must 
not  be  confounded  with  vesical  paralysis  from  injury  or  disease  of  the 
spinal  cord,  and  should  receive  due  consideration  as  an  important  factor  in 
all  cases  of  obstructive  disease  of  the  urinary  organs.  There  is  a  certain 
amount  of  physiologic  atony  that  always  occurs  in  the  healthy  bladder  as 
the  individual  grows  older,  its  expulsive  power  being  greater  in  the  young 
boy  than  in  the  adult.  The  normal  distension  to  which  the  bladder  is 
subjected  gradually  diminishes  its  muscular^  power.  Vesical  atony  may 
result  pathologically  from  voluntary  retention  for  a  length  of  time.  This 
can  be  easily  verified  by  experiment  upon  one's  self.  It  will  be  found  that 
the  urinary  stream  is  not  only  delayed,  but  lacks  its  usual  force.  In  persons 
of  sedentary  habits  habitual  neglect  of  the  calls  of  Xature  will  produce 
permanent  atony.  True  retention  may  result  from  voluntary  suppression 
of  the  call  to  urinate,  the  bladder  refusing  to  contract  even  when  the  op- 
portunity occurs. 

Symptoms. — The  symptoms  of  an  aggravated  case  of  atony  are  chiefly 
dribbling  of  urine  and  the  usual  signs  of  retention.  The  amount  of  paresis 
of  the  sphincter  vesicse — which  may  or  may  not  be  involved — determines 
the  question  of  retention.  After  prolonged  retention  the  power  of  the  ves- 
ical sphincter  is  overcome,  and  the  urine  dribbles  away  involuntarily.  This 
condition  is  termed  "retention  with   overflow,"  and  should  be  promptly 


VESICAL    ATONY.  837 

recognized.  Surgeons  are  very  often  delnded  into  the  belief  that  there  is 
no  retention  because  the  bladder  appears  to  be  constantly  emptying  itself. 
This  mistake  is  often  made  in  retention  from  prostatic  disease,  with  a  fatal 
result. 

In  the  lesser  grades  of  atony  the  patient  experiences  difhculty  in  com- 
pletely emptying  the  bladder,  and  endeavors  to  supplement  the  detrusor 
urinse  by  bringing  the  abdominal  muscles  into  play.  Very  often  the  patient 
discovers  that  the  bladder  can  be  assisted  in  emptying  itself  of  its  contents 
by  pressing  upon  the  hypogastrium  with  the  hand.  In  some  slight  cases 
no  symptoms  are  noticeable  save  dribbling  of  urine  after  the  act  of  mic- 
turition has  been  apparently  completed.  This  symptom  is  liable  to  suggest 
urethral  stricture.  Dribbling  of  urine  at  night  is  not  unusual,  in  even  mild 
cases  of  atony.  This  shows  a  complicating  atony  of  the  true  vesical  sphinc- 
ter. Marked  and  progressive  atony  eventually  leads  to  complete  retention, 
with  or  without  overflow,  and,  secondarily,  cystitis  usually  develops  from 
infection. 

Eetention  from  atony  may  be  differentiated  from  that  due  to  organic 
obstruction  by  the  passage  of  a  catheter.  In  simple  atonic  retention  the 
instrument  passes  with  little  or  no  difficulty,  and  the  urine  escapes  in  a 
passive,  uniform,  down-trickling  stream,  save  when  pressure  is  made  upon 
the  hypogastrium  and  during  deep  inspiration.  In  ordinary  retention  there 
is  usually  marked  obstruction  at  some  jDoint,  and  the  flow  of  urine  from 
the  catheter  is  comparatively  forcible.  In  prolonged  obstructive  retention 
this  means  of  differentiation  may  not  be  available  on  account  of  secondary 
and  pronounced  aton3^ 

The  results  of  severe  atony  are  serious.  Germ-infection  and  inflamma- 
tion of-  the  bladder  generally  supervene  sooner  or  later,  with  consequent  ac- 
cumulation of  muco-pus  and  the  products  of  urinary  decomposition  upon 
the  vesical  mucosa.  More  or  less  absorption  of  these  materials  occurs,  pro- 
ducing chronic  toxemia,  as  stated  in  connection  with  urine-fever.  These 
materials,  being  thrown  out  by  the  skin,  may  produce  eczema  in  some  of  its 
various  forms.  More  or  less  impairment  of  the  renal  functions  develops 
after  a  time,  and  actual  renal  disease,  with  consequent  uremia,  is  not  rare. 
Acute  cystitis,  and  even  sloughing  of  the  vesical  walls,  sometimes  occurs, 
under  which  circumstances  the  typhoid  state  and  death  generally  super- 
vene. This  result  is  very  apt  to  occur  if  the  distended  bladder  be  too  sud- 
denly emptied  after  prolonged  retention,  for  reasons  elsewhere  given. 

Tkeatmext. — The  treatment  of  vesical  atony  involves  many  measures 
already  suggested  in  connection  with  other  vesical  diseases.  Whenever  an 
obstructive  cause  is  foimd,  it  must  be  removed.  Incision  of  a  narrow 
meatus  sometimes  works  wonders.  In  one  of  the  author's  cases  meatotomy 
speedily  cured  a  case  of  vesical  atony  of  several  years'  standing,  although 
the  meatus  was  not  especially  small.  The  atony  in  this  case  was  evidently 
the  result  of  reflex  inhibition  of  the  detrusor  urinae  from  meatal  contraction 


838  XEUEOSES  OF  THE  BLADDEE. 

and  irritation.  In  conditions  of  debility  or  cachexia,  tonics,  especially  the 
nervines,  are  indicated.  Strychnin  is  nsnally  the  main-stay  of  treatment. 
It  should  be  given  preferably  by  hypodermic  injection.  The  faradic  cur- 
rent is  apt  to  prove  beneficial. 

In  all  cases  of  atony  the  urine  should  be  drawn  off  twice  or  thrice  daily, 
and  the  bladder  washed  out  with  a  mild  antiseptic  solution,  whether  re- 
tention or  inflammation  are  present  or  not.  In  some  cases  of  simple  atony 
injections  of  cold  sterilized  water  give  good  results  in  the  restoration  of 
vesical  tonicity. 

TESICAL    PAEALYSIS. 

True  paralysis  of  the  vesical  walls  is  an  infrequent  affection,  differing 
markedly  in  this  respect  from  vesical  atony,  which  enters  so  largely  into 
the  clinical  history  of  organic  urinary  affections. 

Etiology. — Vesical  paralysis  only  arises  from  disease  or  injury  of  the 
brain  or  spinal  cord,  the  latter  being  the  structure  most  often  involved. 
There  is  a  possible  exception  to  this  nde,  in  the  cases  described  by  Brown- 
Sequard  as  "reflex  urinary  paralysis."  Anything  that  will  cause  paraplegia 
is  apt  to  develop  vesical  paralysis.  Thus,  it  is  met  with  as  a  consequence 
of  spinal  trauma,  inflammations  of  the  spinal  marrow,  and  pressure  of 
spinal  apoplectic  or  meningeal  effusions.  Syphilomata,  vertebral  displace- 
ments or  caries,  cancer,  and  sarcoma  of  the  spine  may  cause  vesical  paralysis. 

As  a  rule,  vesical  paralysis  comes  on  quite  suddenly,  but  in  cases  due 
to  the  gradually  increasing  pressure  of  neoplasms  or  the  products  of  spon- 
dylitis, and  in  some  cases  of  myelitis,  it  comes  on  very  gradually,  and  the 
stream  of  urine  grows  less  and  less  forcible,  until  finally  complete  retention 
results. 

Wlien  paralysis  occurs,  residual  urine  is  always  left  after  urination, 
and  undergoes  decomposition,  with  the  usual  train  of  evils  met  with  in 
such  conditions  of  the  bladder.  The  urine  soon  becomes  thick,  ill  smelling, 
and  full  of  ropy  mucus  or  muco-pus,  and  the  patient  is  compelled  to  urinate 
very  frequently  until  such  time  as  the  bladder  loses,  in  great  measure,  its 
sensibility.  Complete  paralysis  may  supervene  suddenly  in  a  case  hitherto 
slowly  progressing,  in  which  case  retention  occurs  immediately. 

Eesults  of  Vesical  Paralysis. — The  local  results  of  vesical  paral- 
ysis may  be  retention  with  overflow,  acute  cystitis,  vesical  gangrene,  ulcer- 
ation, or  calculus.  Great  depression  and  nervous  irritability  are  usual. 
True  incontinence  of  urine  is  likely  to  exist  as  a  consequence  of  involve- 
ment of  the  sphincter  vesicae. 

The  urine  upon  examination  presents  an  excessive  quantity  of  mucus, 
or  muco-pus,  triple  and  earthy  phosphates,  and,  under  the  microscope, 
swarms  of  vibrios.     The  odor  is  usually  strongly  ammoniacal. 

The  kidneys  become  involved  by  ascending  infection  in  most  pro- 
longed cases.     Oftentimes  the  patient  becomes  completely  worn  out  by  all 


VESICAL    PAKALTSIS.      INCONTINENCE    OF    TJEINE.  839 

these  unnecessary  evils,  and  dies  as  the  direct  effect  of  what  might  have 
been  avoided,  in  most  instances,  by  careful  attention  on  the  part  of  his 
physician.  Vesical  paralysis  per  se  is  of  but  little  moment,  if  proper  treat- 
ment be  adopted  to  prevent  its  secondary  evils. 

Treatment.  —  The  treatment  of  vesical  paralysis  is  chiefly  proph- 
ylactic of  cystitis.  The  bladder  should  be  regularly  evacuated  and  irri- 
gated, as  suggested  in  the  treatment  of  atony.  In  this  manner  urinary 
stagnation  and  overdistension  of  the  vesical  walls,  with  their  resultant 
inflammation,  may  be  prevented.  When  retention  and  cystitis  occur,  they 
require  the  same  treatment  as  under  other  circumstances.  Internal  uri- 
nary antiseptics  are  often  useful.  Little  or  nothing  can  be  accomplished 
in  the  treatment  of  the  paralysis  per  se,  excepting  when  the  paraplegia  is 
amenable  to  treatment,  which,  unfortunately,  is  rarely  the  case. 

INCONTINENCE    OF    UEINE. 

This  disagreeable  and  annoying  afi:ection  consists  of  an  involuntary 
escape  of  the  urine,  either  constantly  or  at  intervals.  It  occurs  in  connec- 
tion with  spinal  paralysis  in  some  cases,  this  being  the  only  form  of  incon- 
tinence that  the  surgeon  is  likely  to  meet  with  often  in  the  adult.  True 
incontinence  without  spinal  paralysis  is  seen  but  rarely  in  adult  life.  The 
form  of  inability  to  retain  the  urine  that  results  from  inflammatory  states 
of  the  vesical  neck  is,  however,  often  mistaken  for  true  incontinence. 

True  incontinence  of  urine  is  frequent  among  children.  It  is  usually 
due  to  weakness  or  atony  of  the  sphincter  vesicae  and  adjacent  muscular 
structures:  i.e.,  the  cut-ofl:  muscle.  The  trouble  may  be  either  active  or 
passive,  this  being  dependent  upon  the  tonicity  of  the  detrusor  urins.  If 
this  be  normal,  the  urine  comes  away  in  a  forcible  stream  whenever  the 
cut-off  muscle  and  vesical  sphincter  are  off  guard,  as  they  are  during  sleep. 
This  is  the  form  generally  met  with  in  children.  When,  however,  the 
detrusor  is  atonic,  or  paralyzed,  and  the  cut-off  and  sphincter  weakened  or 
paretic,  dribbling  of  urine  is  constant.  This  form  is  observed  in  spinal 
paralysis.  ' 

In  a  large  majority  of  cases  of  active  incontinence  in  children  the  cause 
is  reflex  irritation  of  the  vesical  neck  from  contiguous  or  remote  pathologic 
conditions;  thus,  it  may  be  due  to  diseases  of  the  rectum  and  anus,  ascar- 
ides  recti,  or  to  vesical  calculus.  Stricture  in  the  adult  male  sometimes 
produces  incontinence.  In  reflex  incontinence  the  patient  often  dreams 
of  urinary  desire  and  involuntarily  yields  to  it.  In  this  respect  there  is 
a  strong  resemblance  between  incontinence  of  urine  and  nocturnal  emis- 
sions. 

Struma  is  sometimes  productive  of  uricemia  in  children,  and  the  re- 
sultant irritating  crystals  of  uric  acid  in  the  urine  occasionally  cause 
incontinence.  In  women,  uterine  disease,  urethral  caruncle,  vesical  calculus, 
and  hysteria  are  the  chief  causes.     As  a  rule,  it  will  be  found  that  the 


840  XEUEOSES  OF  THE  BLADDEE. 

subjects  of  incontinence  of  urine  are  neurotic,  strumous,  cachectic,  or  de- 
bilitated, or  perhaps  suffering  from  local  disease  of  the  urinary  organs, 
either  as  a  primary  condition  or  secondary  to  spinal  disease.  It  is  to  be 
remembered,  therefore,  that  there  are  both  local  and  general  conditions  to 
be  taken  into  consideration  in  the  etiology  of  urinary  incontinence. 

Teeatmext. — The  treatment  of  incontinence  requires  careful  consid- 
eration of  the  causes  of  the  disease.  These  are  often  such  as  are  readily 
removed,  with  resulting  immediate  relief  of  the  urinar}^  symptoms.  If 
ascarides,  calculus,  stricture,  rectal  or  anal  diseases  exist,  they  require  at- 
tention. General  debility,  cachexias  of  various  kinds,  hysteria,  and  struma 
demand  measures  of  a  general  character,  such  as  cold  baths,  nux  vomica, 
codliver-oil,  iron,  quinin,  and  jDhosphorus  in  the  way  of  tonics,  and,  such 
sedatives  and  antispasmodics  as  valerian,  asafetida,  jDotassic  bromid,  and 
belladonna.  If  the  patient  does  not  tolerate  plunge-baths  or  shower-baths, 
cold  sponging  should  be  advised.  A  change  of  air  and  scene  is  sometimes 
necessary.  "When  the  urine  is  highly  acid,  showing  a  tendency  to  lithemia 
or  gout,  the  citrate  or  acetate  of  potassium,  lithia,  colchicum,  and  a  large 
daily  quantity  of  water  are  indicated.  By  increasing  the  secretion  of  urine 
in  the  day-time  we  may  often  so  habituate  the  bladder  to  the  pressure  of  a 
large  quantity  of  water,  that  it  becomes  tolerant  of  its  contents  at  night. 

When  paralysis  of  the  bladder  exists,  the  treatment  is  that  of  the  pri- 
mary disorder. 

When  incontinence  is  associated  with  inflammatory  affections  of  the 
mucous  membrane  of  the  urinary  tract,  the  balsams  are  beneficial.  In  the 
adult,  the  combined  use  of  faradism  and  cantharides  is  most  often  success- 
ful in  true  incontinence.  The  author  has  used  the  faradic  ciirrent  by  means 
of  the  urethral  electrode  with  considerable  success.  Old  persons  require 
the  regular  use  of  the  catheter  and  vesical  irrigations.  In  children  much 
may  be  done  to  break  up  the  habit  by  awakening  the  little  patient  and 
inducing  him  to  urinate  several  times  during  the  night.  In  young  pa- 
tients the  best  internal  remedy  is  belladonna  in  full  doses,  in  combination 
with  the  citrate. of  potassium.  Santonin  often  acts  well,  whether  intestinal 
worms  exist  or  not.  It  has  been  recommended  that  the  preputial  orifice  be 
sealed  with  collodion  at  bed-time  in  boys  suff'ering  from  incontinence,  thus 
breaking  up  the  habit  by  preventing  the  escape  of  the  urine. 

There  is  a  rare  form  of  the  disease  sometimes  seen  in  children  suffering 
from  chorea.  It  is  choreiform  in  character, — chorea  of  the  bladder, — and 
its  treatment  is  that  of  the  general  neurosis.  The  author  has  obtained  the 
best  results  from  asafetida,  santonin,  and  the  valerianates  in  these  cases. 
There  is  a  question  whether  quite  a  proportion  of  cases  of  apparently  simple 
incontinence  in  children  are  not  due  to  a  mild  local  chorea  affecting  the 
detrusor  and  cut-off  muscles.  Valerian,  santonin,  and  bromid  of  potassium 
certainly  act  very  promptly  in  many  cases.  Lest  the  advocates  of  the 
"worm'^  theory  of  all  the  ailments  to  which  childhood  is  subject  advance 


INCONTIXEXCE    OF    UKIXE.  841 

it  in  exj)lanation  of  the  beneficial  effect  of  santonin  in  such  cases,  the 
author  will  state  that  this  drug  has  proved,  in  his  hands,  one  of  the  most 
reliable  of  antispasmodics.  In  epilepsy  it  is  far  superior  to  the  bromids, 
on  the  average.  Chorea  of  the  bladder  is  sometimes  met  with  in  the  adult 
unassociated  with  general  chorea. 

Circumcision  or  meatotomy  are  often  required.  The  occasional  pas- 
sage of  the  cold  sound,  followed  by  silver  nitrate  in  weak  solution,  is  some- 
times very  successful  in  toning  up  the  weakened  sphincter  and  relieving 
reflex  irritation  of  the  vesical  neck.  Anal  or  rectal  disease,  and  especially 
ascarides  recti^  may  require  attention. 


PART  IX. 

SUEGICAL  AFFECTIOXS  OF  THE  KIDXEY  A.\  D  UHETER. 


CHAPTER  XXXYI. 

SURGICAL  AFFECTIONS  OF  THE  KIDlSTEY. 

SUEGICAL   AXATOMT,   MaLFOEMATIOXS,   AXD   AxOMALIES   OF  THE   KiDNET; 

Floatixg  axd   Movable   Kidxey;    Eenal   Calculus;    Pyelitis; 
Ptoxepheosis;    Peeixepheitic  Abscess;    Suegical  Xepheitis. 

suegical  axatoily  of  the  kidxey. 

AccuEATE  knowledge  of  the  gross  anatomy  of  the  kidney  is  more 
essential  to  a  correct  understanding  of  the  surgical  diseases  of  the  organ 
than  of  its  strictly  medical  diseases.  The  kidne5'S  are  designed  for  the 
secretion  of  urine  and  the  excretion  of  important  products  of  the  retro- 
grade metamorphosis  of  tissue.  They  are  situated  in  the  lumbar  region 
posterior  to  the  peritoneum,  one  upon  each  side  of  the  spinal  column,  ex- 
tending from  the  eleventh  rib  almost  to  the  crista  ilii.  The  left  kidney 
extends  do\m-ward  a  little  farther  than  the  right.  Each  organ  is  about  four 
inches  long,  two  and  a  half  inches  in  breadth,  about  an  inch  and  a  quarter 
thick,  and  weighs  from  four  to  five  ounces.  The  kidneys  are  surrounded 
by  cellular  tissue  and  a  liberal  padding  of  fat.  In  a  general  way  the  kid- 
neys are  shaped  something  like  a  large  bean,  the  concavity  of  which,  the 
hilum,  is  directed  toAvard  the  spinal  column,  and  contains  the  upper  ex- 
panded portion  of  the  ureter  known  as  the  pelvis  of  the  kidney.  The  kid- 
ney is  invested  by  a  proper  fibrous  capsule  of  dense  connective  and  elastic 
tissue.  The  pelvis  of  the  kidney  subdivides  into  several  dilations,  the 
calices,  into  which  the  tubuli  of  the  organ  empty.  The  kidney-structure 
proper  is  divided  into  a  medullary  portion  composed  of  reddish  conic 
masses,  the  pyramids,  these  again  being  composed  of  straight  tubes  that 
open  into  the  calices,  and  a  cortical  portion  constituting  the  surface  of  the 
organ  and  containing  the  blood-vessels  and  terminations  of  the  uriniferous 
tubules.  In  the  cortical  substance  are  found  the  glomeruli,  or  Malpighian 
bodies,  little  spheroidal  bodies  that  form  the  most  distinctive  feature  of  the 
secreting  structure  of  the  organ,  the  function  of  which  is  to  form  the  urine. 
The  blood-supply  of  the  kidneys  is  derived  from  the  renal  arteries,  which 
enter  at  the  hilum  and  divide  into  four  or  five  branches  supplying  the 
kidney-structure. 

The  concave  border  of  the  kidney  is  occupied  by  the  pelvis  of  the 

(842) 


MALFOEMATIOKS    AND    ANOMALIES    OF    THE    KIDNEY.  843 

organ,  which  consists  of  a  membranous,  or  bag-like,  expansion  of  the  ureter, 
large  at  its  base,  or  attachment  to  the  kidney,  and  small  at  its  opening  into 
the  ureter  proper.  The  ureter  is  a  membranous  tube  about  the  size  of  a 
goose-quill  and  from  sixteen  to  eighteen  inches  in  length,  the  function  of 
which  is  to  convey  the  urine  from  the  pelvis  of  the  kidney  to  the  bladder. 

MALFOEMATIONS   AND   ANOMALIES. 

Malformations  and  anomalies  of  the  kidney  are  not  of  great  pathologic 
importance,  being  chiefly  anatomic  curiosities.  Supernumerary  kidneys 
have  been  seen,  and  a  case  is  related  in  which  an  extra  pair  of  kidneys 


Fig.   193. — Single  median  kidney  lying  below  bifurcation  of 
the  aorta.     (After  Moullin.) 

situated  below  what  were  apparently  the  normal  ones  were  the  seat  of  in- 
tense inflammation,  while  the  latter  were  perfectly  healthy.  Cases  are  not 
infrequently  seen  in  which  one  kidney  is  congenitally  absent.  Two  cases 
of  this  kind  have  come  under  the  author's  observation  that  were  discov- 
ered accidentally  during  autopsy.  Anomalies  in  number,  size,  and  direction 
of  the  ureter  are  by  no  means  uncommon.  In  one  of  the  author's  cases 
there  was  a  double  ureter  upon  one  side,  both  tubes  being  rather  smaller 
than  their  single  fellow.  In  another  case  there  was  a  supernumerary 
ureter  on  each  side.  Anomalies  of  the  ureter — such  as  atresia,  stricture, 
kinking  or  twisting  of  the  tube — bear  a  very  important  relation  to  cystic 
kidney,  especially  the  hydronephrotic  form.     Single  kidney  is  more  im- 


su 


SUEGICAL    AFFECTIONS    OF    THE    KIDXEY. 


portant  than  other  anomalies,  from  the  fact  that  if  the  organ  becomes  dis- 
eased there  is  no  companion-organ  to  act  compensatorily.  Instances  have 
been  recorded  in  which  nephrectomy  has  been  performed  npon  one  organ 
with  a  fatal  result,  and  on  autopsy  no  kidney  was  found  upon  the  opposite 
side.  Such  cases,  although  extremely  rare,  should  put  the  surgeon  on  his 
guard  as  to  the  possibility  of  the  existence  of  the  anomaly,  and  consequent 
caution  and  conservatism  should  be  exercised  in  the  performance  of  ne- 
phrectomy. 

HoBSESHOE  KiDXEY. — The  most  interesting  anomaly  of  the  kidney  is 
what  has  been  termed  the  horseshoe  lidney.  In  this  malformation  there  is 
more  or  less  fusion  of  the  two  organs  in  front  of  the  spinal  column,  their 
blood-vessels  inosculating  and  the  kidney-structure  being  continuous  from 
one  to  the  other.  This  anomaly  is  only  to  be  discovered  post-mortem,  as 
a  rule. 


Fig.   194. — Horseshoe  kidney.      (After  Morris.) 


TRAUMA   OF   THE    KIDXEY. 

The  kidney  is  usually  injured  by  direct  violence,  although  severe  con- 
cussion has  been  known  to  contuse  or  lacerate  one  or  the  other  organ.  The 
author  recalls  a  case  in  which  a  fall  upon  the  buttocks  from  an  elevation 
of  about  fifteen  feet  produced  more  or  less  extensive  injury  of  the  right 
kidney,  with  hematuria  and  swelling  in  the  loin  lasting  for  several  weeks. 
Eecovery  occurred  without  operation,  hence  the  exact  nature  of  the  trau- 
matism could  not  be  determined.  The  extent  of  the  injury  varies  from 
slight  contusion  or  laceration  to  complete  disorganization. 

Symptoms. — The  kind  and  severity  of  the  symptoms  depend  upon  the 
degree  and  character  of  the  injury  and  the  nature  and  extent  of  damage 
sustained  by  surrounding  structures.  Hemorrhage  is  severe  when  the  large 
vessels  are  injured,  but,  if  the  ureter  be  torn  across,  little  or  no  blood  may 
appear  in  the  urine.     In  cases  in  which  the  large  vessels  at  the  hilum  are 


TEAUMA    OF    THE    KIDNEY.  845 

rujDtiired,  especially  if  the  investing  peritoneum  is  torn,  fatal  internal 
hemorrhage  ma_y  occnr.  In  some  eases  blood  does  not  appear  in  the  nrine 
immediately,  but  only  after  an  interval  of  several  hours.  Ureterform  clots 
may  be  passed,  their  journey  down  the  ureter  being  heralded  by  colic  re- 
sembling that  produced  by  the  passage  of  a  stone  from  the  kidney.  Ure- 
teral obstruction  and  lij^dronephrosis  sometimes  result  from  blocking  up 
of  the  duct  by  clots.  The  quantity  of  blood  entering  the  bladder  may  be 
sufficient  to  distend  that  viscus  Avith  coagula.  This,  however,  is  rare.  In 
some  instances  a  large  hematoma  forms  about  the  kidney  in  the  loin.  The 
hemorrhagic  effusion  sometimes  extends  downward  to  the  pelvis,  passing 
out  of  the  inguinal  ring  into  the  scrotum. 

Where  the  ureter  or  renal  pelvis  is  torn,  urinary  extravasation  occurs 
in  the  loin.  If  the  peritoneum  be  lacerated,  the  urine  escapes  into  the  peri- 
toneal cavity,  causing  fatal  peritonitis  and  death  within  a  few  days.  When 
limited  to  the  loin,  septic  cellulitis  develops  and,  if  unrelieved  by  operation, 
results  fatally.  Suppurative  nephritis  or  perhaps  pyonephrosis  may  occur 
in  rare  instances.  Complete  suppression  of  urine  is  likely  to  occur  where 
both  kidneys  are  injured,  and  sometimes  results  from  the  reflex  effect  of  in- 
jury of  one  kidney. 

Peognosis. — If  the  peritoneum  is  not  torn  and  where  there  is  no 
urinary  extravasation,  recovery  is  the  rule.  Severe  laceration  of  the  large 
blood-vessels  is  likely  to  result  in  fatal  hemorrhage.  Eecover}^  may  occur 
after  suppuration.  In  such  cases  a  fistula  of  greater  or  less  duration  is 
liable  to  result.  . 

Treatment. — In  cases  of  slight  or  moderate  severity,  complete  rest, 
with  milk  diet  and  the  application  of  ice-bags  to  the  loin  are  usually  all 
that  is  required.  Turpentine  internally  is  of  service  in  checking  the  renal 
hemorrhage.  Ergot  is,  of  course,  the  most  universally  used  remed}^,  but 
in  the  authors  experience  it  has  been  inferior  to  turpentine  in  urinary 
hemorrhage.  Where  general  symptoms  of  severe  hemorrhage  or  hematuria 
continue,  an  exploratory  incision  is  required.  The  hemorrhage  should  be 
checked  by  ligature  and  antiseptic-gauze  packing  where  possible.  When 
packing  fails,  nephrectomy  is  demanded.  When  a  large  hematoma  exists, 
or  suppuration  is  imminent,  an  attempt  may  be  made  to  relieve  it  by  aspira- 
tion. This  must  not  be  done  too  early,  else  recurrence  of  the  hemorrhage 
may  follow.  If  at  any  time  urinary  extravasation  or  suppuration  be  sus- 
pected, aspiration  will  usually  clear  up  the  diagnosis.  Both  suppuration 
and  extravasation  demand  free  incision.  Where  extravasation  or  symptoms 
of  sepsis  exist,  there  should  be  no  delay  in  cutting,  '\^^len  the  peritoneum 
is  involved,  celiotomy  and  lumbar  incision  are  both  demanded.  The  ab- 
domen should  be  flushed  with  sterilized  water  and  the  wound  in  the  peri- 
toneum closed.  The  kidney  may  be  dealt  with  from  either  front  or  rear. 
Both  anterior  and  posterior  drainage  are  necessary.  Wounds  of  the  kidnev, 
gunshot  or  punctured,  should  be  managed  upon  the  same  principles  as  the 


846  SUEGICAL    AFFECTIOXS    OF    THE    KIDXEY. 

class  of  injuries  already  dealt  with.  In  sneli  Avounds,  however,  there  is 
greater  liabilit}'  to  complicating  conditions,  that  must  be  dealt  with  upon 
their  merits,  than  in  contusions  and  lacerations  of  the  organ. 

MOVABLE    KIDXEY. 

Like  some  other  conditions  of  the  organ,  movable  kidney  is  probably 
more  frequent  than  is  generallj''  supposed,  and  it  is  probable  that  the  af- 
fection really  constitutes  quite  a  proportion  of  cases  of  obscure  abdominal 
disease.  Inasmuch  as  the  organ  is  by  no  means  firmly  bound  in  its  nor- 
mal position,  but  is  allowed  more  or  less  freedom  of  movement — under 
pressure  at  least,  and  undoubtedly  with  the  respiratory  movements, — it 
would  be  surprising  if  displacement  of  the  organ  did  not  occasionally  occur. 
The  affection  is  most  frequent  among  females.  W.  jSTewman  found  in  290 
cases,  252  in  women  and  38  in  men,  a  proportion  of  about  one  in  seven. ^ 
Henry  Morris  makes  a  very  similar  statement.^  The  right  kidney  is  more 
frequently  affected  than  the  left,  although  both  are  sometimes  involved.  In 
173  cases  of  Newman's  152  were  on  the  right  side,  12  on  the  left,  and  9 
involved  both  organs.  In  a  general  wa}',  renal  displacement  and  mobility 
seem  to  bear  a  more  or  less  definite  relation  to  muscular  strain  and  exertion. 
In  Germany,  in  particular,  movable  kidney  is  observed  quite  frequently 
among  the  lower  classes,  among  whom  a  large  proportion  of  the  hard  phys- 
ical work  is  carried  on  by  women. 

The  influence  of  pressure  is  well  shown  by  the  manner  in  which  the 
tumor  formed  by  a  dislocated  kidney  will  move  about  in  the  abdomen  under 
sources  of  mechanic  disturbance.  It  may  press  forward  against  the  ante- 
rior abdominal  wall  and  be  mistaken  for  some  form  of  abdominal  tumor,  or 
it  may  be  pushed  downward  into  the  pelvis,  where  it  may  be  confounded 
with  uterine  or  ovarian  growths.  Mistakes  are  especially  liable  to  happen 
if  adhesions  form,  fixing  the  organ  in  its  abdominal  position.  In  many 
instances  of  wandering  kidne}-  the  affection  is  congenital.  ISTewman  divides 
renal  displacements  into  two  classes,  viz.:  movable  kidney — the  most  fre- 
quent variet}^ — in  which  the  kidney  moves  behind  the  peritoneum,  and 
true  floating  kidney,  Avhich  is  attached  to  the  spine  by  a  mesonephron  and 
floats  about  freely  in  the  peritoneal  cavity.^ 

Etiology. — The  causes  of  wandering  kidney  are  several.  It  is  prob- 
able that  an  exposed  position  of  the  organ  from  a  sparsity  of  connective 
tissue  about  it  or  an  unusual  laxity  and  flabbiness  of  its  areolar  capsule 
exists  as  a  predisposing  cause  in  quite  a  number  of  cases.  When  the  ab- 
dominal walls  are  lax  and  flabby,  thus  affording  a  poor  support  to  the 
abdominal  viscera,  there  is  likely  to  be  a  tendency  to  displacement  of  the 


^  "Surgical  Diseases  of  the  Kidney/'  W.  ISTeAvman. 
-  "Surgical  Diseases,  of  the  Kidney,"  Henry  Morris. 
^  Op.    cit. 


MOVABLE    KIDNEY.  847 

kidney  that  may  result  in  its  actual  occurrence  under  the  influence  of  com- 
paratively slight  causes^  such  as  moderate  muscular  exertion.  Eepeated 
pregnancies  seem  to  have  a  direct  influence  in  the  causation  of  renal  dis- 
placement, by  producing  pendulous  abdomen  and  diminishing  support  to 
the  kidney.  Falls,  hard  riding,  shocks,  and  strains  experienced  in  athletic 
exercises  have  been  known  to  cause  the  affection.  A  cause  that  has  been 
said  to  be  effective  among  the  working-classes  is  the  use  of  a  tight  strap  or 
band  to  support  the  clothing.  Corsets,  if  laced  tightly,  may  possibly  have 
the  same  effect. 

The  most  important  etiologic  factor  is  absorption  of  the  perirenal  fat. 
The  kidney  is  but  poorly  supported  at  best,  and,  once  this  fatty  cushion  is 
removed,  a  certain  degree  of  movement  is  almost  inevitable.  In  some  cases 
a  congenital  defect  of  development  of  the  fatty  capsule  may  exist.  Dis- 
eases that  produce  profound  nutritive  disturbance,  with  consequent  wast- 
ing, may  act  as  a  predisposing  cause  of  movable  kidney.  Once  the  normal 
support  of  the  kidney  becomes  impaired,  very  slight  causes  may  produce 
dislocation  of  the  organ. 

Blows  upon  the  lumbar  region  may  possibly  displace  the  kidney;  cases 
attributed  to  this  cause  have  been  recorded.  A  moderate  degree  of  dis- 
placement having  occurred,  the  movements  of  respiration,  the  weight  of 
the  clothing,  or  the  pressure  of  the  pregnant  uterus  will  assist  in  increas- 
ing the  displacement.  The  right  kidney  occupies  a  more  exposed  position 
than  the  left,  and  this,  in  combination  with  its  relation  to  the  liver  already 
alluded  to,  especially  predisposes  to  displacement,  and  explains  why  it  is 
more  frequently  displaced  than  its  fellow,  as  shown  clinically  by  the  re- 
corded cases.  It  is  probable  that  counter-pressure  by  the  liver  may  favor 
dislocation  of  the  kidney  under  strain  or  abdominal  compression.  The 
right  kidney  slips  from  between  the  abdominal  wall  and  the  liver  just  as 
a  bean  slips  from  between  the  thumb  and  finger  when  pressed  upon. 

Symptoms. — The  symptoms  of  wandering  kidney  are  very  variable  and 
by  no  means  characteristic.  In  some  cases  a  very  moderate  degree  of  dis- 
placement is  sufficient  to  produce  quite  severe  symptoms,  while  in  others 
marked  displacement  is  productive  of  comparatively  little  discomfort.  One 
reason  for  the  obscurity  surrounding  the  diagnosis  of  these  cases  is  that  the 
function  of  the  kidney  is  rarely,  if  ever,  disturbed,  the  organ  being  appar- 
ently perfectly  normal  and  performing  its  functions  as  under  ordinary  cir- 
cumstances. Symptoms  referable  to  the  uterus  and  bladder  have  been 
noted  in  connection  with  wandering  kidney  and  are  probably  dependent 
upon  reflex  nervous  disturbance  produced  by  the  displacement  of  the  organ 
rather  than  upon  any  direct  influence  exerted  by  it.  G-eneral  nervous  dis- 
turbances such  as  hysteria  in  the  female,  melancholia,  and  hypochondriasis 
have  been  referred  to  wandering  kidney.  Such  cases,  however,  are  attrib- 
utable to  the  psychic  disturbance  incidental  to  a  knowledge  of  the  exist- 
ence of  some  abdominal  derangement  rather  than  to  any  direct  influence 


848  SUEGICAL   AFFECTIONS    OF    THE    KIDNEY. 

upon  the  nervous  system  or  general  nutrition.  In  common  with  other  af- 
fections of  the  abdominal  viscera,  all  of  which  organs  have  an  intimate 
anatomic  and  physiologic  association  with  the  sympathetic  system,  wander- 
ing kidney  produces  more  or  less  disturbance  of  the  digestive  functions,  as 
often  evidenced  by  colicky  pains  referred  to  the  stomach  and  bowels,  and 
dyspepsia,  with  or  without  flatulence.  Certain  cases  of  flatulence,  dyspepsia, 
and  dilation  of  the  stomach  have  been  attributed  to  pressure  of  wandering 
kidney  upon  the  duodenum,  this  pressure  being  supposed  to  cause  reten- 
tion of  a  portion  of  the  contents  of  the  stomach,  which,  decomposing,  pro- 
duces gaseous  distension  of  that  organ  and  irritation  of  its  mucous  membrane. 

Abdominal  pains  of  a  dragging  or  tugging  character,  and  a  sensation 
as  of  something  falling  down  or  moving  about  in  the  abdominal  cavity, 
particularly  when  the  patient  rises  from  a  sitting  or  lying  to  a  standing 
posture  or  makes  unusual  muscular  exertion,  constitute  the  most  charac- 
teristic symptoms  of  wandering  kidney.  Severe  pains  with  tenderness  of 
the  tumor  formed  by  the  displaced  organ  occasionally  occur,  and  have  been 
attributed  to  a  localized  peritonitis  of  the  serous  investment  of  the  organ 
or  to  simple  neuralgia.  Disturbance  of  the  hepatic  functions  due  to  press- 
ure and  irritation  of  the  liver  produced  by  the  kidney-tumor  have  been 
noted.  The  disease,  as  a  rule,  is  not  fatal  to  life.  Cases  have  been  reported, 
however,  in  which  the  patient  has  apparently  died  from  exhaustion  due  to 
chronic  stomachic  disturbance,  continual  pain,  and  nervous  depression. 
The  most  serious  menace  is  the  possibility  of  malignant  disease's  developing 
in  the  displaced  organ.  This  danger  is  often  of  the  most  important  con- 
sideration in  deciding  the  question  of  operation. 

Diagnosis. — The  diagnosis  of  wandering  kidney  is,  as  a  rule,  quite 
readily  made.  In  some  instances  the  surgeon  is  first  consulted  regarding 
an  abdominal  tumor,  the  character  of  which  is  easily  determined  upon 
j)hysical  examination  by  its  form  and  extreme  mobility.  The  tumor  is  usu- 
ally found  between  the  free  border  of  the  ribs  and  the  crista  ilii,  being 
most  readily  detected  by  bimanual  examination  with  the  patient  lying  upon 
the  face.  In  thin  subjects  the  displaced  kidney  may  be  grasped  between 
the  hands  and  outlined  quite  readily.  In  fat  subjects,  however,  it  is  not 
always  easy  to  detect  the  kidney.  When  the  tumor  has  been  discovered  it 
will  be  found  that  it  can  easily  be  pressed  back;  indeed,  it  will  often 
recede  spontaneously  into  the  normal  position  of  the  kidney  if  the  patient 
be  placed  in  the  dorsal  decubitus. 

There  are  several  affections  for  which  floating  kidney  may  be  mistaken. 
When  the  organ  becomes  displaced  downward  into  the  pelvic  cavity  it  may 
be  erroneously  diagnosed  as  a  small  ovarian  or  fibroid  tumor.  Operations 
have  been  performed  for  the  removal  of  ovarian  tumors  which,  upon  open- 
ing the  abdomen,  have  been  found  to  be  displaced  kidney.  This  has  hap- 
pened to  very  expert  operators.  The  possibility  of  mistaking  a  distended 
gall-bladder  or  movable  liver  for  wandering  kidney  must  be  remembered. 


MOVABLE    KIDNEY.  849 

Tumors  of  the  omentum  may  be  mistaken  for  wandering  kidney,  a 
diagnosis  being  perhaps  impossible  without  opening  the  abdomen.  En- 
largement and  displacement  of  the  spleen  simulate  movable  kidney  to  a 
certain  extent,  but  the  peculiar  shape  and  relatively  large  size  of  the  splenic 
tumor  usually  make  the  diagnosis  comparatively  easy.  Pelvic  tumors  of 
various  kinds  may  often  be  excluded  by  vaginal  examination  and  by  aspira- 
tion— the  latter  procedure  being,  however,  rarely  wan-antable. 

Teeatment. — The  treatment  of  wandering  kidney  should  be,  in  the 
majority  of  cases,  strictly  conservative,  surgical  interference  being  unwar- 
rantable save  in  extreme  cases.  The  patient  should  avoid  muscular  strain, 
and  if  constipation  exists  it  should  be  relieved,  to  prevent  pressure's  being 
brought  to  bear  upon  the  kidney — through  the  medium  of  the  intervening 
viscera — by  the  abdominal  muscles  during  defecation.  An  abdominal  band- 
age of  knitted  elastic  is  often  serviceable  in  retaining  the  kidney  in  its  nor-- 
mal  position.  Pads  and  trusses  of  various  kinds  have  been  suggested  and 
have  been  indifferently  useful.  In  cases  in  which  mechanic  support  fails 
to  hold  the  kidney  in  place,  or  if  pain,  hypochondria,  dyspepsia,  flatulence, 
and  inconvenience  in  locomotion  continue  in  spite  of  abdominal  support, 
the  only  recourse  is  a  surgical  operation. 

Two  methods  of  operating  for  movable  kidney  are  in  vogue,  viz.:  (a) 
nephrectomy — complete  removal  of  kidney;  (b)  nephrorrhaphy — fixation  of 
the  kidney.  Nephrectomy  has  given  only  fair  results;  thus,  in  one  early 
series  of  16  cases,  6  were  fatal;  of  the  6  fatal  cases,  however,  the  kidney  was 
diseased  in  3.^  Although,  as  is  well  known,  a  single  kidney  is  sufficient  for 
the  needs  of  the  economy  under  normal  circumstances,  it  must  be  admitted 
that  in  case  the  sole  remaining  kidney  is  unsound  or  should  ever  become 
diseased  the  patient's  chances  of  recovery  are  likely  to  be  slight.  Again, 
the  operation  of  nephrectomy  through  the  lumbar  incision  might  ^Dossibly 
be  performed  without  the  operator's  having  ascertained  whether  or  not  the 
patient  has  more  than  one  kidney,  and,  inasmuch  as  nephrectomies  have 
been  performed  that  have  proved  fatal  because  the  patient's  only  kidney 
has  been  removed,  it  is  well  to  seriously  consider  this  particular  objection 
to  nephrectomy  for  wandering  kidney.  The  operation  should  certainly 
never  be  performed  until  ureteral  catheterization,  cystoscopy,  or  the  Harris 
method  has  proved  that  the  patient  has  two  kidneys.  Neither  should  it  be 
performed  where  both  kidneys  are  diseased.  It  is  better  practice  to  attempt 
fixation  of  the  kidney  in  all  cases  unless  the  affected  organ  has  undergone 
malignant  degeneration.  This  is  best  performed  by  making  a  lumbar  in- 
cision and  stitching  the  fibrous  and  adipose  capsule  of  the  kidney  to  the 
lips  of  the  lumbar  wound,  following  the  method  hereafter  to  be  described. 
The  literature  of  this  operation  is  not  yet  extensive,  but  is  daily  increasing 
and,  so  far  as  it  goes,  offers  considerable  encouragement  for  the  future  of 


^Harris,  American  Journal  of  the  Medical  Sciences,  July,  1882. 


850  SUEGICAL   AFFECTIONS    OF    THE    KIDNEY. 

the  procedure.  The  method  is  certainly  well  worth  a  trials  the  more  espe- 
cially as  it  is  not  very  dangerous  in  competent  hands  in  the  majority  of 
eases.  Should  it  fail,  there  will  still  be  left  the  dernier  ressort  of  nephrec- 
tomy. An  operation  of  this  kind,  which  has  for  its  object  not  only  the  cure 
of  invalidism  and  the  relief  of  great  physical  suffering,  but  also  the  pres- 
ervation of  an  important  excretory  organ,  is  certainly  well  worthy  of  con- 
sideration in  all  serious  cases  of  floating  kidney,  now  that  we  have  the  benefit 
of  modern  aseptic  surgical  methods.  The  success  thus  far  attained  has  been 
sufficient  to  obtain  general  recognition  of  the  method  as  a  rational  surgical 
procedure. 

There  are  several  diseases  of  the  kidney  that  properly  fall  to  the  con- 
sideration of  the  surgeon,  because  of  their  greater  or  less  amenability  to 
strictly  surgical  methods  of  treatment.  From  a  numeric  stand-point  the 
surgical  diseases  of  the  kidney  preponderate  over  those  of  a  purely  medical 
character,  although,  on  account  of  the  comparative  ease  with  which  morbus 
Brightii  is  detected,  the  physician  is  more  often  called  upon  to  treat  renal 
disease  than  the  surgeon. 

NEPHEALGIA. 

Pain  referable  to  the  kidney  is  necessarily  always  symptomatic,  yet 
certain  cases  arise  in  which  we  are  unable  to  determine  the  cause,  even 
approximately.  In  by  no  means  rare  instances  pain  in  the  region  of  the 
kidney  is  probably  a  true  neuralgia  and  should  be  regarded  from  that  stand- 
point, although,  as  in  all  forms  of  neuralgia,  the  surgeon  should  occupy 
himself  with  a  careful  search  for  the  exciting  cause  of  the  pain.  As  a  rule, 
renal  pain  of  a  neuralgic  character  is  dependent  upon  some  irritating 
property  of  the  urine.  It  is  therefore  met  with  most  frequently  in  patients 
affected  by  a  gouty  or  rheumatic  diathesis.  Lithemia  is  especially  liable  to 
develop  it.  It  is  by  no  means  necessary  that  a  definite  calculus  should  exist 
in  order  that  the  solid  matters  of  the  urine  may  produce  pain  in  the  kidney. 
The  sharp  crystals  of  uric  acid  or  calcium  oxalate  axe  all-sufficient  to  pro- 
duce a  painful  degree  of  irritation  of  the  renal  pelvis,  the  more  especially 
because  the  local  irritation  acts  upon  tissues  that  the  gouty  blood  condi- 
tion has  made  hyperesthetic  and.  irritable. 

Nephralgia  may  be  brought  on  by  exposure  to  cold  and  partake  of  the 
characters  of  ordinary  rheumatism.  In  this  event  it  may  or  may  not  be 
associated  with  rheumatic  symptoms  elsewhere.  It  is  probable  that  in  some 
cases  of  so-called  lumbago  the  kidney  is  the  seat  of  most  of  the  rheumatic 
pain,  the  renal  disturbances  being  of  a  congestive  character.  Congestion 
may  in  all  probability  exist  without  urinary  symptoms. 

That  the  urine  may  acquire  properties  by  virtue  of  which  it  acts  as  an 
irritant  to  the  kidney  is  well  shown  by  the  severe  nephralgia  so  often  pro- 


EENAL    CALCULUS.  851 

duced  by  the  oil  of  sandal.  This  is  generally  associated  with  considerable 
pain  and  lameness — probably  reflex — of  the  lumbar  muscleS;,  which,  so  far 
as  it  goeS;,  is  confirmatory  of  what  has  been  said  regarding  the  occasional 
coincidence  of  lumbago  and  nephralgia.  Eecurrent  attacks  of  nephralgia 
are  usually  due  to  some  serious  organic  cause,  such  as  calculus,  cancer,  or 
tuberculosis,  a  definite  calculus  being  the  most  frequent  factor  in  its  etiology. 

Teeatment. — The  cause  must  be  removed  where  possible.  Where  the 
cause  is  not  removable,  and  in  cases  in  which  none  can  be  found,  nephralgia 
demands  attention  upon  its  own  merits. 

In  general,  nephralgia  demands  anodynes  just  as  does  neuralgia  in  any 
situation.  The  application  of  anodyne  poultices  over  the  lumbar  region  is 
of  great  service.  Dry  cupping  is  one  of  our  most  reliable  remedies,  a  single 
application  often  being  sufficient  to  give  complete  relief.  In  supposedly 
rheumatic  cases  salicylate  of  soda  is  demanded.  Lithemia  demands  the 
dietetic  and  medicinal  measures  elsewhere  recommended.  Diuretics  and 
large  quantities  of  pure  water  are  especially  indicated. 

EENAL    CALCULUS. 

Stone  in  the  kidney  is  one  of  the  most  important  of  the  surgical  diseases 
of  the  organ.  The  causes  of  this  disease  have  been  outlined  in  the  general 
remarks  upon  the  etiology  of  urinary  calculus  and  do  not  require  detailed 
repetition.  As  a  result  of  a  special  diathesis — usually  the  lithic  or  gouty,  but 
sometimes  the  oxaluric — a  deposit  of  crystalline  material — uric  acid,  urates, 
or  calcium  oxalate — occurs  in  the  renal  tubuli.  From  the  tubuli  the  deposit 
may  be  washed  into  the  pelvis  of  the  kidney,  in  which  event  it  forms  the 
nucleus  of  a  calculus.  Earely  the  material  forms  by  accretion  a  calculus  in 
the  parenchyma  of  the  organ.  The  condition  often  first  manifests  itself  by 
a  copious  deposit  of  reddish-brown — brick-dust — deposit  of  sandy  material  in 
the  voided  urine,  with  or  without  additional  symptoms  in  the  way  of  pain  in 
the  back — nephralgia — and  a  greater  or  less  degree  of  cystitis,  with  frequent 
and  painful  micturition.  These  latter  symptoms  are  a  natural  result  of  the 
irritation  of  the  mucous  membrane  produced  by  the  chemic  and  mechanic 
properties  of  the  sharp  crystals  of  the  special  urinary  deposit. 

Given  the  special  diathesis,  it  is  probable  that  apparently  trivial  causes 
may  give  rise  to  a  precipitation  of  the  solid  matters  of  the  highly  concen- 
trated urine.  It  is  claimed  that  sudden  chilling  of  the  surface  of  the  body 
will  produce  it:  a  view  that  seems  reasonable  enough,  for  crystals  which 
will  remain  in  solution  in  warm  urine  precipitate  when  it  cools.  It  would 
seem  especially  liable  to  occur  from  this  cause  if  the  patient  be  markedly 
rheumatic  or  gouty.  It  is  quite  likely  that  a  cold  draught  striking  the  back 
is  most  apt  to  cause  the  difficulty,  for  in  this  direct  manner  the  kidneys  may 
become  chilled.  Eeasoning  from  the  fact  that,  as  a  consequence  of  cooling 
of  the  urine  in  the  renal  tubuli,  uric-acid  crystals  are  often  found  in  the 
kidneys  of  subjects  recently  dead,  this  view  seems  rational  and  sound. 


852  SUKGICAL    AFFECTIOXS    OF    THE    KIDXEY. 

It  is  by  no  means  easy  to  explain  the  deposition  of  crystals  in  all  cases, 
for,  even  when  the  nrine  is  very  concentrated,  its  solid  matters  are  not  apt 
to  crystallize  under  ordinary  circumstances;  when  a  foreign  body  is  present, 
however,  the  process  is  a  simple  one  and  is  precisely  like  the  crystallization 
of  rock  candy  upon  a  string.  It  is  possible  that  in  some  cases  of  gravel  a 
slight  catarrh  or  thickening  of  the  tubules  exists,  which  aids  mechanically 
in  the  deposition  of  solid  matters  from  the  urine.  Such  a  condition  of 
catarrhal  or  hyperemic  thickening  may  possibly  appear  and  disappear  within 
a  very  short  time  and  leave  no  effects  save  the  deposit  of  gravel. 

A  prolonged  debauch,  or  the  ingestion  of  an  excessive  quantity  of  nitrog- 
enized  food  at  some  particular  time,  may  act  as  the  exciting  cause  of  renal 
deposits.  "When  sabulous  material  has  once  formed  in  the  kidneys,  it  may 
become  agglutinated  by  mucus,  with  the  resultant  formation  of  a  formed 
calculus.  This  often  occurs  without  the  intervention  of  mucus.  After  a 
definite  concretion  of  appreciable  size  has  formed,  it  may  lodge  in  any  por- 
tion of  the  genito-urinary  tract,  and  by  successive  accretions  of  solid  urinary 
matters  may  attain  an  unlimited  size. 

Secondary  phosphatic  calculus  may  form  in  the  renal  pelvis  in  disease 
of  that  structure  with  retention  of  decomposing  residual  urine.  This  con- 
dition is,  however,  rare. 

Symptoms. — "When  a  stone  of  any  size  exists  in  the  kidney,  it  is  likely 
to  produce  considerable  irritation,  with  more  or  less  constant  pain  in  the 
back  and  paroxysms  of  nephralgia  of  greater  or  less  frequency  and  severity. 
If  small,  it  may  give  no  symptoms  while  in  the  kidney,  the  first  sign  of  its 
existence  being  renal  colic  as  it  passes  downward  through  the  ureter. 
Sometimes  the  kidney  is  extensively  destroyed  without  special  symptoms, 
perhaps  without  the  slightest  pain  referable  to  the  kidney.  Pressure  over 
the  kidney  may  elicit  pain,  but  there  is  no  special  objective  diagnostic  sign 
indicating  the  existence  of  kidney-stone  in  the  majority  of  cases.  In  the 
matter  of  diagnosis  Keyes  says: — 

In  kidney-stone  it  may  sometimes  be  noticed  tliat  the  blood-disks,  oval,  round, 
and  spindle-shaped  epithelial  and  scattered  pus-cells,  which  the  urine  is  pretty  sure 
to  contain,  become  increased  in  quantity  after  exercise,  while  they  sensibly  diminish 
or  perhaps  entirely  disappear  after  rest  in  bed  for  a  few  days. 

Pain  and  discomfort  referable  to  the  lumbar  region  on  physical  exertion 
are  occasionally  observed,  but  are  not  characteristic.  The  same  may  be  said 
of  the  sensation  of  tenderness  sometimes  experienced  by  patients  with 
kidney-stone  on  leaning  the  back  against  a  firm  body  such  as  the  back  of  a 
chair  in  sitting  or  of  a  buggy  in  riding.  The  latter  symptom,  however,  is 
sometimes  complained  of  by  lithemic  patients  in  whom  no  stone  exists.  In 
a  case  of  the  author's  the  gentleman — a  physician — complains  of  this  symp- 
tom quite  constantly,  being  annoyed  by  it  especially  while  making  his  calls. 
In  this  case  there  have  never  been  any  other  symptoms  that  might  be  fairly 


EEXAL    CALCULUS.  bOO 

termed  suspicious  of  stone.  Tlie  tenderness  and  pain  incidental  to  lumbo- 
abdominal  neuralgia  may  possibh'  be  mistaken  for  renal  symptoms. 
Hematuria  is  frequent,  but  not   constant. 

Wliile  hemorrhage  taken  alone  is  no  more  than  a  symptom  which 
should  lead  to  inquiry  as  to  the  possibility  of  renal  stone,  it  is  quite  im- 
portant when  associated  with  certain  other  symptoms.  Especially  is  it  of 
value  when  it  occurs  coincidently  with  or  follows  nephralgia.  In  some 
cases  the  issuance  of  blood  from  one  or  the  other  ureter,  as  seen  via  the 
cystoscope,  enables  the  surgeon  to  determine  not  only  the  renal  origin  of 
the  hemorrhage,  but  also  whether  one  or  both  are  involved.  Many  cases  of 
renal  stone  are  never  productive  of  hemorrhage. 

The  x-ray  has  been  shown  to  be  serviceable  in  the  diagnosis  of  renal 
calculus.  The  extent  to  which  the  method  is  applicable  is,  of  course,  un- 
determined as  yet. 

That  extensive  renal  calculus  may  exist  without  pain  or  tenderness 
referable  to  the  kidney  is  Avell  shown  by  the  following  case  of  the  author's:- — 

Case. — A  man,  now  aged  46  years,  came  under  treatment  about  ten  years  ago 
suffering  with  deep  and,  for  a  time,  surgically  impermeable  traumatic  stricture.  It 
was  some  weeks  before  a  filiform  could  be  passed  into  the  bladder,  on  account  of  the 
tortuous  formation  of  the  stricture.  The  bladder  could  be  evacuated  fairly  well  after 
prolonged  straining.  Aside  from  the  stricture,  the  patient  had  always  been  healthy. 
His  habits  were  temperate,  and  his  history  was  excellent.  There  was  no  history  of 
hereditary  gout,  rheumatism,  tuberculosis,  or  other  constitutional  disease.  After 
some  weeks  of  careful  treatment  the  stricture  was  dilated  to  a  caliber  of  Xo.  30 
French.  Since  his  first  course  of  treatment  the  patient  has  appeared  occasionally  for 
the  passage  of  the  sound.  There  was  a  moderate  aiiiount  of  cystitis,  secondary  to 
the  stricture.  Pyelitis  was  present;  hence  the  urine  did  not  clear  up  perfectly  after 
the  successful  treatment  of  the  stricture,  but  remained  quite  cloudy.  Exacerbations 
of  cystitis  occurred  from  time  to  time,  necessitating  irrigation  and  the  usual  general 
and  local  treatment  for  that  condition.  The  cystitis  was  finally  apparently  under 
control  when,  without  increase  in  the  symptoms  referable  to  the  bladder,  the  urine 
began  to  show  a  marked  deposit  of  pus.  This  increased,  there  being  no  attendant 
constitutional  symptoms.  Careful  examination  showed  the  origin  of  the  sudden  in- 
crease of  pus  to  be  the  pelves  of  the  kidneys.  The  pus  gradually  increased  until 
the  urine  contained  the  largest  proportion  the  author  had  ever  seen,  aside  from  certain 
exceptional  cases  of  evacuation  of  an  abscess  into  the  cavity  of  the  bladder.  There 
were  no  casts,  the  urinary  deposit  consisting  of  pure  pus  mixed  with  a  small  amount 
of  epithelium  from  the  bladder  and  renal  pelvis.  This  profuse  discharge  of  pus 
continued  for  some  months  without  having  any  specially  deleterious  effect  upon  the 
patient's  health.  Suddenly,  however,  he  began  to  have  moderate  fever,  loss  of  appe- 
tite, emaciation,  night-sweats,  and  diarrhea.  Within  a  week  he  became  extremely 
debilitated,  but  not  sufficiently  so  to  necessitate  his  going  to  bed.  There  was  no  clear 
indication  for  surgical  interference;  hence  the  sole  reliance  was  internal  medication, 
the  usual  urinary  antiseptics,  tonics,  and  stimulants  being  given.  After  this  con- 
dition had  lasted  for  several  weeks  without  material  improvement,  Clark's  solutions 
of  iodin  and  chlorid  of  gold  were  administered  hypodermically  with  most  excellent 
results,  the  patient  soon  regaining  his  usual  condition  of  health  and  the  pus  in  the 
urine  being  reduced  to  a  minimum.  From  the  beginning  of  his  urethral  trouble  the 
patient  had  never  made  the  slightest  complaint  of  pain  in  the  back  or  symptoms 


854 


SUEGICAL    AFFECTIOXS    OF    THE    KIDXET. 


referable  to  the  kidney  or  ureter,  nor  had  he  ever  been  affected  by  anything  tliat 
might  be  termed  renal  colic.  There  was  at  no  time,  nor  has  their  ever  been  excepting 
after  the  operation  upon  the  kidney  that  will  shortly  be  described,  the  slightest  trace 
of  blood  in  the  urine. 

The  patient  remained  in  a  condition  of  health  quite  satisfactory  to  himself  until 
the  onset  of  the  difficulty  for  which  the  operation  under  consideration  was  performed. 
The  urine  remained  quite  cloudy,  and  contained,  at  all  times,  a  moderate  amount  of 
muco-pus.  Some  months  afterward,  however,  recurrent  chills  and  fever,  vomiting,  loss 
of  appetite,  and  night-sweats  suddenly  developed.  Five  days  later,  for  the  first  time 
since  he  came  under  treatment,  the  patient,  was  compelled  to  take  to  his  bed,  where 
he  remained  several  days,  after  which  he  arose  and  remained  an  ambulant  patient 
until  operated  upon.  There  was  still  no  pain  or  tenderness  in  the  vicinity  of  the  kid- 
neys, and  it  was  difficult  to  convince  him  that  even  a  suspicion  of  a  collection  of 
pus  in  one  or  the  other  loin  was  warrantable.  After  careful  study  of  the  case  for 
about  a  week,  the  author  became  convinced  that  there  was  suppuration  in  the  vicinity 
of  the  right  kidney,  and,  as  the  liver  was  considerably  enlarged,  a  complicating 
hepatic   abscess   was    suspected,    this    suspicion    being   otherwise    justified   by   slight 


rig.   195. — Renal  calculus  removed  in  the   author's   case   of 
hepato-nephrolithotomy. 


jaundice.  The  tongue  was  heavily  coated;  temperatui-e  ranged  from  102°  F.  in  the 
morning  to  103°  F.  in  the  evening.  As  there  was  no  definite  tumor  in  the  flank  and 
no  well-outlined  local  symptoms,  the  diagnosis  was  not  clear  until  nearly  a  week 
later,  when  pus  was  found  anteriorly  just  below  the  free  border  of  the  ribs,  after 
repeated  attempts  to  detect  it  with  the  aspirator.  An  operation  was  decided  upon, 
and  the  author  determined  to  open  anteriorly  with  the  view  of  first  operating  upon 
the  hepatic  abscess  that  was  believed  to  be  present,  the  intention  being  to  leave  the 
abscess  in  the  region  of  the  kidney  for  future  consideration. 

Operation. — An  incision  was  made  in  the  abdominal  wall  just  beyond  the  outer 
border  of  the  rectus  muscle,  extending  from  the  free  margin  of  the  ribs  to  the 
crest  of  the  ilium.  On  cutting  through  the  fascia  transversalis,  the  peritoneum  was 
found  to  be  adherent  to  a  coil  of  intestine,  which  in  turn  was  adherent  to  the  anterior 
surface  of  the  greatly-enlarged  liver.  Only  cautious  dissection  prevented  injury  to 
the  bowel.  Repeated  attempts  at  aspiration  were  necessary  before  pus  was  finally 
encountered,  the  needle  being  passed  backward  and  inward  in  the  direction  of  the 
spine.  Pus  was  found  at  a  much  greater  depth  than  had  been  anticipated  from  the 
results  of  the  aspiration  performed  before  the  abdomen  was  opened.  The  needle  was 
left  in  position  and  an  incision  made  in  the   thickened  visceral  and  parietal  peri- 


EEXAL    CALCULUS. 


855 


toneum,  which  were  closely  fused  together  over  the  surface  of  the  liver.  On  turning 
down  the  inferior  edge  of  the  incised  peritoneum,  it  was  found  to  be  firmly  adherent 
to  the  liver  and  to  the  coil  of  intestine  already  alluded  to,  the  general  peritoneal 
cavity  thus  being  effectually  walled  off.  The  Paquelin  cautery  was  now  made  to 
follow  the  needle  and  the  pus-cavity  was  finally  entered,  this  being  rather  difl&cult 
because  of  the  small  area  of  the  operation-field.  On  entering  the  abscess-cavity  in  the 
liver,  about  4  ounces  of  creamy  pus  escaped.  On  exploring  the  cavity  Avith  the  finger, 
it  was  found  to  extend  backward  so  that  its  long  axis  was  directed  toward  the 
region  of  the  kidney.  Detecting  fluctuation  in  the  posterior  wall  of  the  abscess,  the 
finger  was  deliberately  pushed  through  the  thin  wall,  opening  into  a  second  abscess, 
evidently  perinephritic  in  character.  On  opening  the  perinephritic  abscess,  a  large 
quantity  of  pus  escaped,  and  with  it  a  small  amount  of  sabulous  material,  which  ex- 
cited the  suspicion  that  renal  stone  was  present.    With  great  effort  the  finger  reached 


W 


M5*aP^ 


Fig.   196. — Calculus  imbedded  in  lower  portion  of  renal  pelvis. 
(After  Moullin.) 


the  pelvis  of  the  kidney,  which  was  found  enormously  dilated,  presenting  an  opening 
toward  the  perinephritic  abscess-cavity.  The  region  of  the  pelvis  of  the  kidney  was 
no  sooner  touched  than  a  hard  body  was  felt,  and  on  passing  the  finger  through  the 
incapsulating  wall  of  the  renal  pelvis  a  calculus  was  distinctly  outlined.  Thinking 
that  the  calculus  was  not  of  large  dimensions  because  of  the  small  size  of  the  present- 
ing part  reached  by  the  finger,  an  attempt  was  made  to  extract  it  with  a  pair  of 
forceps,  and,  the  presenting  point  breaking  off,  a  calculous  mass  was  extracted  which, 
as  shown  by  its  facets,  Avas  evidently  a  secondary  calculus  fused  upon  one  of  larger 
size.  Several  particles  of  calculous  material  now  escaped  from  the  pelvis  of  the 
kidney  into  the  abscess-cavity,  and  were  removed  with  the  finger.  It  was  decided 
to  remove  the  larger  mass  of  calculus  entire  if  possible,  and  finally,  by  the  aid  of 
long  curved  pedicle-forceps  and  a  lithotomy-scoop,  the  remainder  of  the  calculus  was 
removed  unbroken.     The  wound  was  deeply  tamponed  with  iodoform  gauze  for  drain- 


856  SUEGICAL   AFFECTIONS    OF    THE    KIDNEY. 

age,  this  being  substituted  in  a  few  days  by  rubber  tubing,  the  latter  being  entirely 
removed  at  the  end  of  four  weeks. 

The  illustration  shows  the  calculus,  natural  size.  The  entire  mass  weighed  746 
grains.  As  will  be  observed,  it  is  ovoid  in  form  and  tuberculated.  It  is  composed 
of  a  number  of  uric-acid  calculi  fused  together  by  phosphatic  laminae. 

The  subsequent  history  of  the  case  was  uneventful.  Three  months  after  the 
operation  the  wound  was  almost  closed,  there  being  but  a  small  amount  of  pus  and 
no  urine  escaping  from  the  resulting  fistula.  The  patient  gained  rapidly  in  weight 
and  strength,  the  urine  vastly  improved  in  appearance,  and  it  was  evident  that 
his  life  had  been  greatly  prolonged  by  the  operation.  At  'the  present  time,  four  years 
after  operation,  and  eleven  years  since  he  first  consulted  the  author,  he  is  in  good 
health,  although  the  urine  is  not  clear  nor  the  fistula  completely  closed.^ 

The  case  is  exceptional:  — 

1.  Because  of  the  large  size  of  the  calculus. 

2.  The  entire  absence  of  all  symptoms  referable  to  renal  calculus,  notwithstand- 
ing the  fact  that  the  patient  Avas  most  carefully  observed  for  some  years. 

3.  The  difficulty  of  diagnosis  incidental  to  pyelitis  from  ascending  infection 
secondary  to  a  condition  entirely  independent  of  the  renal  calculus. 

4.  The  extraordinary  method  of  opei-ation  necessitated  by  the  exigencies  of  the 
case. 

The  enormous  size  to  wliicli  renal  calenli  may  attain  is  shown  by  the 
following  unique  case,  reported  by  Charles  Adams,  of  Chicago: — 

Case. — Mary  D.  G.,  aged  38,  first  seen  in  July,  1895,  suffering  from  severe  renal 
colic.  She  had  suffered  from  similar  attacks  at  irregular  intervals  for  seventeen  years. 
After  the  first  colic  in  1878  there  were  several  attacks  during  the  succeeding  eighteen 
months;  then  for  three  months  the  attacks  were  frequent — sometimes  tAvo  or  three 
weekly.  Following  this  was  a  long  quiescent  period.  In  1888  a  brief  attack  occurred. 
During  the  last  three  months  of  a  pregnancy  that  came  to  term  in  December,  1889, 
suffering  was  severe  and  almost  continuous.  Two  weeks  after  delivery  an  especially 
severe  attack  was  followed  by  the  expulsion,  per  urethram,  of  four  calculi. 

Five  years  elapsed  without  severe  paroxysms  Avhen,  in  the  spring  of  1895,  the 
attacks  became  severe  and  frequent  until  the  time  of  operation.  There  had  never 
been  absolute  freedom  from  pain  in  the  left  renal  region  since  the  first  attack,  but  the 
patient  had  considered  herself  well  when  not  confined  to  bed  by  acute  colic.  At 
the  time  of  my  first  visit  there  was  no  question  as  to  the  diagnosis,  but  the  affected 
region  was  so  sensitive  that  palpation  was  unbearable;  hence  no  idea  was  gained  of 
the  size  of  the  calculi.  Operation  was  advised  and  preliminary  catheterization  of  the 
ureters  suggested  to  ascertain  the  condition  of  the  right  kidney,  as  the  left  was  prob- 
ably worthless  and  required  removal  with  the  calculi.  The  patient  recovered  quickly 
from  the  acute  att-ack,  and  went  to  Colorado,  returning  in  improved  health  in  October. 
In  November  another  attack  occurred,  followed  by  attacks  in  January,  February,  and 
March. 

In  April,  1896,  I  was  again  called  and  found  the  patient  prostrated  by  an 
attack  of  two  Aveeks'  duration  attended  by  continual  vomiting,  steady  emaciation, 
and  severe  pain,  demanding  large  and  frequent  doses  of  morphia.  The  urine  contained 
pus  and  considerable  blood.  Operation  was  advised,  but  the  patient  would  not  consent 
until  after  the  subsidence  of  acute  symptoms.  Her  condition,  however,  became  worse 
from  day  to  day  and  on  May  1st  I  was  again  called.     There  was  at  this  time  an 


^  Since  the  above  was  written  the  author  has  removed  some  calculous  material 
from  the  track  of  the  fistula,  and  it  is  now  closed. 


EENAL    CALCULUS. 


857 


increase  of  intensity  of  the  condition  above  noted,  plus  an  exhausting  diarrhea. 
There  was  a  tumor  in  the  left  iliac  region  as  large  as  two  fists;  the  affected  kidney 
was  secreting  urine  and  the  ureter  was  blocked  at  the  renal  end.     The  patient  was 


197. — Enormous  segmented  renal  calculus,  natural  size.     (After  Adams.) 


in  most  unpromising  condition  for  operation,  but  it  was  evident  that  if  anything 
was  done  it  must  be  done  quickly.  I  urged  immediate  removal  to  hospital,  and  that 
being  safely  accomplished  the  operation  was  performed  in  the  afternoon. 


858 


SUEGICAL    AFFECTIONS    OF    THE    KIDNEY. 


Under  chloroform  anesthesia,  incision  was  made,  parallel  to  and  just  below  the 
last  rib,  from  the  sacro-lumbalis  forward  and  downward  to  the  extent  of  three  inches. 
This  incision,  being  carried  through  the  parietes,  exposed  the  peritoneum  anteriorly. 
The  peritoneum  protruded  into  the  wound,  but  was  not  cut.  The  weight  of  the 
calculi  had  displaced  the  kidney  downward  and  forward  to  such  an  extent  that  it 
was  necessary  to  have  it  pushed  up  into  the  loin  by  pressure  through  the  anterior 
abdominal  wall.  The  kidney,  being  cleared  of  fat,  was  incised  at  the  upper  third  of 
its  convex  surface  and  the  calculous  mass  exposed.  Incision  was  followed  by  the 
escape  of  some  urine,  and  free  hemorrhage.  The  latter  being  checked  by  hot  water 
and  pressure,  and  the  edges  of  the  renal  wound  held  up  to  the  external  incision  by 
forceps,  the  upper  calculus  was  carefully  enucleated.  It  Avas  intimately  adherent  to 
the  kidney  in  places.  Next,  with  a  slight  enlargement  of  the  renal  incision,  the 
smooth,  spear-shaped  stone  was  extracted.  With  infinite  diflficulty  and  pains  to  avoid 
laceration  of  the  kidnev,  the  large  central  mass  was  finally  freed  from  its  adhesions 


Fig.    198. — Enormous   renal   calculus,   reduced;     segments   separated, 
showing  facets.     (After  Adams.) 


and  removed.  This  necessitated  enlarging  the  parietal  wound  by  a  vertical  cut  from 
the  center  of  the  first  incision  to  the  crista  ilii.  On  account  of  the  closeness  of  the 
last  rib  of  the  ilium  this  incision  was  only  two  and  one-fourth  inches  long,  but 
by  extreme  care  the  mass  Avas  extracted  without  lacerating  the  tissues  to  any 
great  extent.  The  interior  of  the  kidney  was  now  the  shape  of  a  pouch  about  six 
by  three  inches,  from  the  bottom  of  which  were  extracted  the  nine  smaller  stones 
that  filled  the  lower  portion  of  the  renal  cavity.  Exploration  revealed  no  other  cal- 
culus. The  cavity  was  irrigated  with  sterile  hot  water,  the  kidney  sutured  to  the 
fascia  in  position,  a  rubber  drainage-tube  passed  to  the  bottom  of  the  renal  cavity 
and  packed  around  with  strips  of  iodoform  gavize,  the  external  wound  closed  so  far 
as  possible  by  sutures,  and  dressings  applied.  Although  done  as  quickly  as  compatible 
with  safety,  the  operation  consumed  an  hour  and  twenty  minutes,  during  which  time 
the  patient  was  in  imminent  danger  of  collapse,  but  was  freely  stimulated  by  hypo- 
dermics of  strychnia  and  whisky. 

The  stones  are  represented,  actual  size,  in  Fig.   197,  fastened  together  as  they 


EENAL    CALCULUS.  859 

lay  in  the  kidney.  In  Fig.  198  they  are  separated,  showing  their  principal  facets. 
The  nine  smaller  calculi  were  compactly  packed  together  in  the  bottom  of  the  kidney 
below  the  level  of  the  ureteral  opening.  The  spear-shaped  calculus  fitted  into  the 
ureter,  and  as  it  was  movable  on  the  large  mass  on  a  highly  polished  surface,  I  sup- 
pose it  produced  occlusion  only  up  to  a  certain  point,  when  by  the  changes  in  pressure 
produced  by  the  distension  by  urine  it  was  shifted  upward  slightly,  allowing  the 
urine  to  escape.  The  stones  are  uric  acid  in  composition,  with  some  incrustation  of 
phosphates.  The  total  weight  was  226  grams  dry.  For  forty-eight  hours  after  opera- 
tion the  patient  hung  between  life  and  death,  but  since  that  time  she  has  done  well. 
The  urine  is  normal,  and  save  some  vesical  irritation  she  has  had  no  symptoms. 

At  the  date  of  writing  the  patient  has  passed  forty  days  since  operation,  is 
gaining  in  flesh,  and  doing  well  in  every  particular. 

An  instructive  feature  of  this  remarkable  case  is  the  preservation  of 
the  function  of  the  affected  kidney  under  the  prolonged  pressure  of  the 
enormous  mass  of  calculous  material. 

MosBiD  Anatomy. — The  first  pathologic  result  of  renal  stone  is  neces- 
sarily more  or  less  pyelitis.  This  condition  becomes  aggravated  as  the  stone 
increases  in  dimensions.  After  the  stone  attains  a  size  sufficient  to  produce 
a  certain  degree  of  pressure  upon  the  renal  tissue,  atrophy  of  the  latter 
commences.  In  extreme  cases  a  huge  stone  will  be  found  inclosed  in  a 
fibrous  sac  that  was  once  the  kidney.  Abscess  may  result,  and  this  may 
rupture  into  the  cellular  tissue  about  the  kidney,  forming  perinephritic 
abscess.  If  the  ureter  be  blocked  up,  hydronephrosis  or  pyonephrosis  may 
result.  Much  depends  upon  the  extent  of  the  secondary  renal  disease  and 
its  character  as  regards  pus  or  tubercular  infection.  If  one  kidney  be  com- 
paratively healthy,  it  may  carry  on  the  eliminative  function  perfectly 
enough  for  all  practical  purposes;  but  if  both  be  diseased,  uremia  must 
result  sooner  or  later,  its  degree  depending  entirely  upon  the  amount  of 
pathologic  change  in  the  renal  tissues. 

Treatment. — The  therapeutics  of  renal  calculus  embrace  both  med- 
ical and  surgical  means  of  relief.  The  medical  treatment  comprises  (1) 
prophylactic  measures;    (2)  curative  remedies  (rarely);    (3)  palliation. 

Prophylaxis,  palliation,  and  cure  by  internal  medication  are  all  sub- 
served by  the  various  measures  suggested  in  the  chapter  on  genito-urinary 
hygiene.  Of  special  importance  are  exercise,  bathing,  a  non-nitrogenized 
regimen,  and  total  abstinence  from  alcoholics  of  whatever  kind.  Of  more 
importance  than  the  quality  of  the  diet  is  the  question  of  its  digestion  and 
assimilation.  A  moderate  quantity  of  proteids  well  digested  and  properly 
assimilated  is  safer  than  a  vegetable  diet  where  the  latter  is  not  normally 
digested.  Abstinence  from  meat  alone  will  not  effect  the  desired  result. 
As  Henry  Morris  states,  the  poorer  classes,  who  are  often  of  necessity  vege- 
tarians, are  none  the  less  subject  to  calculus.^  That  gout  may  develop  under 
a  vegetable  diet  is  shown  by  the  fact  that  gouty  deposits  are  found  in  parrots. 
How  far  nervous  disturbance  may  enter  into  the  etiology  of  calculus  in 

^  Op.  cit. 


860  SUKGICAL   AFFECTIOXS    OF    THE    KIDXET. 

human  beings  is  an  ojDen  question.  The  anthor  snspects  it  to  he  more 
important  than  is  generally  believed. 

The  enratire  medical  treatment  of  renal  calculns  is  xevx  unreliable,  3^et 
excellent  results  are  apparently  secured  in  not  a  few  cases.  The  treatment 
is  based  upon  the  theory  of  the  possibility  of  dissolving  the  stone  in  loco 
by  remedies  the  action  of  which  is  chiefly  to  increase  the  solvent  properties 
of  the  urine.  Obviously,  the  urine  is  best  adapted  for  the  solution  of  con- 
cretions when  its  specific  gravity  most  nearly  approximates  that  of  pure 
water.  Constant  study  of  the  urine  enables  the  surgeon  to  determine 
whether  his  treatment  is  maintaining  its  specific  gravity  at  the  desired  low 
standard.  The  solvent  treatment  for  calculus  should  include,  in  addition 
to  dietetic  and  hygienic  measures,  the  free  ingestion  of  large  quantities  of 
pure  water — of  which  distilled  water,  with  or  without  lithia,  is  the  type — 
and  the  administration  of  such  alkaline  diuretics  as  citrate  and  acetate  of 
potassium.  These  drugs,  to  be  efi^ective,  should  be  given  in  doses  of  from 
30  to  60  grains  three  or  four  times  dail3^  Lithia  in  full  doses  is  also  serv- 
iceable. Potassium  iodide  has  seemed  to  be  of  service.  A  cure  is  never 
to  be  promised  from  the  solvent  treatment,  though  exceptional  cases  have 
resulted  favorably  under  it.  Wliile  the  so-called  solvent  treatment  is  rarely 
curative,  it  is  usually  palliative,  and  prophylactic  of  further  calculous 
deposit.  Additional  measures  of  iDalliation  consist  of  narcotics,  anti- 
spasmodics, and  rest,  as  exemplified  in  the  treatment  of  nephritic  colic. 
The  surgical  treatment  is,  of  necessity,  operative,  and  will  be  discussed  later. 

Nepheitic  Colic. — The  more  or  less  constant  pain  over  a  kidney 
affected  by  stone  is  often  varied  from  time  to  time  by  acute  exacerbations 
due  to  efi'orts  on  the  part  of  the  kidney  to  exjDel  the  intruder,  efforts  that 
are  sometimes  successful. 

When  the  calculus  is  of  very  small  size  it  may  pass  through  the  ureter 
into  the  bladder  with  little  or  no  pain;  but,  if  large  enough  to  irritate  the 
ureter,  pain  of  most  agonizing  character  may  result.  The  pain  is  referred 
to  the  loin  that  has  been  the  seat  of  irritation,  and  radiates  along  the  sper- 
matic cord,  into  the  testicle,  and  down  the  inner  aspect  of  the  thigh  of  the 
affected  side.  The  testicle  is  drawn  snugly  up  to  the  external  ring  b}^  spas- 
modic retraction  of  the  cremaster  muscle.  These  phenomena  are  a  result 
of  reflex  irritation  of  the  genital  branch  of  the  genito-crural  nerve,  being 
analogous  to  the  knee-pain  experienced  in  disease  of  the  hip.  Like  all  of 
the  abdominal  organs,  the  ureter  is  intimately  associated  with  the  sym- 
pathetic system:  consequently  any  injury  of,  or  morbid  impression  upon, 
it  produces  profound  de^Dression  and  the  patient  feels  weak  and  faint;  in 
short,  he  presents  the  cool,  moist  skin  and  general  appearance  of  shock. 
This  condition  always  results  when  a  sensitive  tissue  is  pinched  or  strangu- 
lated, as  is  best  shown  in  strangulated  hernia.  Nausea  and  vomiting  are 
usual,  and  constipation  is  apt  to  supervene.  The  urine  is  scanty,  high- 
colored,  and  often  bloody,  the  calls  to  urinate  being  frequent  and  sometimes 


RENAL    CALCULUS.  861 

more  or  less  painful.  Complete  suppression  may  occur.  In  prolonged  eases 
a  rise  of  temperature  may  be  noted.  The  pain  continues  with  more  or 
less  marked  remissions  and  exacerbations  until  the  stone  reaches  the  blad- 
der^ when  the  symptoms  suddenly  cease  and  the  patient  is  soon  as  well  as 
ever.  This  descent  may  last  only  a  few  hours,  but  often  it  requires  several 
days.  The  author  has  recently  seen  in  consultation  a  case  of  three  weeks' 
duration.  The  phenomena  just  described  are  known  under  the  names  of 
nephritic  colic  and  "gravel." 

Whenever  an  attack  of  this  kind  has  been  experienced  the  patient 
should  be  apprised  of  the  probability  of  its  recurrence,  and  the  possibility  of 
the  development  of  a  vesical  calculus  sooner  or  later.  If  the  stone  does  not 
pass  out  through  the  urethra  with  the  urine,  it  will  inevitably  become  by  ac- 
cretion a  vesical  calculus  of  greater  or  less  dimensions.  This  is  the  origin 
of  most  of  the  nuclei  found  in  stone  in  the  bladder.  It  is  important,  there- 
fore, to  watch  the  urine  carefully  for  several  days  after  an  attack  of  gravel. 
The  discovery  of  the  concretion  will  permit  the  surgeon  to  reassure  the 
patient  to  a  certain  extent  regarding  his  future  comfort,  so  far,  at  least, 
as  the  stone  in  question  is  concerned. 

Treatment.  —  The  treatment  of  nephritic  colic  is  necessarily  chiefly 
palliative,  as  we  cannot  immediately  modify  the  existing  condition.  At- 
tention should  be  directed  to  the  relief  of  pain  and  spasm  until  such  time 
as  the  condition  becomes  cured  spontaneously.  Morphin  or  other  opiates 
should  be  given  freely.  The  surgeon  can  at  least  relieve  the  intense  pain. 
The  drug  should  be  given  in  sufficient  quantity  to  allay  the  pain.  It  should 
be  remembered,  however,  that  pain  is  an  antidote  for  opium;  hence,  if  the 
pain  should  suddenly  cease  soon  after  the  patient  has  taken  a  huge  dose  of 
morphin,  fatal  narcotism  might  result.  Opium  relieves  spasm  as  well  as 
pain,  and  is  therefore  doubly  effective  in  renal  colic.  Chloroform  inhala- 
tions may  be  given  if  necessary.  A  full  hot  bath  assists  the  passage  of  the 
stone  by  promoting  general  relaxation.  Hot  poultices  should  be  applied  to 
the  loin  and  side.  The  bowels  should  be  relieved  by  enemata.  A  remedy 
that  has  been  highly  recommended  in  renal  colic  is  hydrangea  in  the  form 
of  the  fluid  extract.  This  should  be  given  in  a  dose  of  5J  every  two  hours. 
In  the  author's  experience  this  remedy  has  been  of  service.  It  is  claimed 
that  hydrangea  has  a  special  effect  upon  the  ureter.  Diluents  and  diuretics 
with  large  quantities  of  water  should  be  freely  given  for  the  purpose  of 
affording  mechanic  assistance  to  the  passage  of  the  gravel. 

When  a  renal  calculus  remains  in  the  pelvis  of  the  kidney  it  sometimes 
attains  an  enormous  size,  filling  the  pelvis  and  calices  completely,  and  event- 
ually causing  atrophy  as  well  as  inflammation,  and  perhaps  abscess,  of  the 
secreting  structure  of  the  kidney.  The  stone  may  become  impacted  in  the 
ureter,  causing  hydronephrosis  or  pyonephrosis,  pyelitis,  or  perinephritic  ab- 
scess. In  either  event  the  patient  is  finally  worn  out  by  pain  and  urinary 
toxemia,  unless  the  case  should  prove  amenable  to  operation. 


863 


SURGICAL   AFFECTIONS    OF   THE    KIDNEY. 


It  is  worthy  of  note  that  in  some  cases  of  nephritic  colic  the  pain  is 
due  to  the  temporary  impaction  of  a  calculus  in  the  uretero-pelvic  orifice. 
The  stone,  being  too  large  to  pass,  suddenly  slips  back  after  a  time,  giving 
almost  instant  relief. 

SUEGICAL   PYELITIS. 

Pyelitis  is  so  rarely  idiopathic — being,  as  a  rule,  secondary  to  diseases 
of  the  genito-urinary  tract  of  a  distinctively  surgical  character — that  it  has 
come  to  be  looked  upon  as  an  almost  exclusively  surgical  affection.  It  has 
even  been  asserted  that  pyelitis  is  never  an  idiopathic  disease:  an  opinion 
with  which  the  author  cannot  agree. 


Fig.  199. — Calculous  pyelonephritis,  with  destruction  of  renal  tissue, 
removed  and  shown  at  a.     (After  Moullin.) 


Calculus 


Idiopathic  or  non-surgical  pyelitis  is  not  common;  still  it  is  more  fre- 
quently met  with  than  is  generally  believed. 

Eich,  highly-seasoned  food,  intemperate  habits,  habitual  overdistension 
of  the  bladder  from  neglect  of  the  physiologic  function  of  micturition,  acid 
urine,  and  exposure  to  cold  are  the  chief  causes  that  may  contribute  to  the 
production  of  a  catarrh  of  the  mucous  membrane  lining  the  renal  pelves. 
The  prolonged  ingestion  of  the  balsams,  cantharides,  or  turpentine  may 
produce  the  same  condition.  Secondary  infection  occurring  in  the  course 
of  the  exanthemata  is  sometimes  an  efficient  cause. 

Etiology. — The  causes  of  surgical  pyelitis  may  be  classified  as  fol- 
lows, it  being  understood  that  some  of  the  etiologic  factors  in  the  first 


SUEGICAL    PYELITIS.  863 

series  may  co-exist  with  any  of  the  others  and  that  the  inflammation  is 
generally  of  the  chronic  type: — 

1.  The  influences  just  enumerated  as  productive  of  idiopathic  and  sim- 
ple (medical)  pyelitis. 

3.  Obstructive  affections  of  the  urinary  tract,  such  as  .stricture  and 
prostatic  hypertrophy,  producing  backward  pressure  and  strain  upon  the 
renal  pelvis,  with,  sooner  or  later,  ascending  infection  from  the  bladder. 

3.  Acute  or  chronic  inflammation  of  the  urinary  tract,  producing 
pyelitis  by  simple  extension. 

4.  Eenal  calculus,  perhaps  associated  with  infection,  either  from  below 
or  through  the  medium  of  the  blood. 

5.  Tumors  and  tubercular  deposit  in  the  renal  structure  or  pelvis,  with 
or  without  associated  mixed  infection. 

6.  Pyemic  abscesses — i.e.,  abscesses  from  general  pus-infection — in  the 
renal  substance  opening  into  the  renal  pelvis. 

The  most  frequent  causes  of  obstruction  to  the  flow  of  urine  are  ves- 
ical calculus,  stricture,  and  enlarged  prostate.  Very  few  cases  of  these  con- 
ditions remain  free  from  more  or  less  severe  pyelitis.  Indeed,  the  existence 
of  chronic  pyelitis  should  be  taken  for  granted  in  every  long-standing  case 
of  the  kind.  As  a  rule,  the  pyelitis  is  of  low  grade  and  due  to  continual 
congestion  and  pressure  irritation  associated  with  mild  infection,  the  in- 
flammation of  the  bladder  which  nearly  always  exists,  extending  gradually 
upward  to  the  kidneys.  In  some  cases  as  a  consequence  of  a  debauch,  ex- 
posure to  cold  and  wet,  or  surgical  interference  with  the  urethra  or  bladder, 
acute  pyelitis  with  its  characteristic  symptoms  is  set  up.  This  may  extend 
to  the  secreting  structure  of  the  kidney — pyelonephritis.  Acute  or  even 
chronic  gonorrheal  inflammation  is  especially  apt  to  extend  suddenly  in 
this  manner.  According  to  Keyes,  the  supervention  of  acute  pyelitis  may 
not  be  announced  by  chill,  fever,  pain,  of  other  symptoms  referable  to  a 
possible  invasion  of  the  renal  pelvis.  If  this  be  true,  constant  care  should 
be  exercised  lest  pyelitis  be  overlooked  altogether. 

Pyelitis  is  sometimes  a  serious  complication  of  pregnancy,  although 
simple  renal  congestion  or  even  nephritis  with  resulting  albuminuria  are 
more  frequent.  The  pyelitis  is  probably  due  to  the  same  cause  as  disease 
of  the  renal  tissue  proper,  viz.:  simple  pressure  by  the  gravid  uterus  pro- 
ducing obstruction  to  the  escape  of  urine  into  the  ureters;  there  is  also, 
undoubtedly,  more  or  less  bruising  from  the  uterine  pressure. 

The  remaining  causes  of  pyelitis  act  alike.  Calculi,  abscesses,  tumors, 
and  tubercular  deposits  produce  pyelitis:  (1)  by  their  irritating  influence 
as  foreign  bodies;  (2)  by  producing  mechanic  obstruction  to  the  escape  of 
urine;  (3)  by  associated  infection.  Blood-clots,  hydatids,  or  cheesy  masses 
of  pus  may  block  up  the  ureter  and  produce  pyelitis.  Pyelitis  is  an  occa- 
sional accompaniment  of  typic  Bright's  disease,  but  more  often  precedes 
nephritis,  being  under  such  circumstances  a  source  of  confusion  in  urinal- 


86i  SUEGICAL    AFFECTIONS    OF    THE    KIDXET. 

ysis.  In  such  cases  the  urine  ■«'ill  show  a  certain  amount  of  albumin  after 
the  inflammation  of  the  renal  structure  jjroper  has  practically  disappeared. 
Acute  nephritis  is  not  infrequently  followed  by  pyelitis. 

Symptoms. — The  s}Tnptoms  of  pyelitis  are  chiefly  pain  in  the  loin  on 
one  or  both  sides  and  discharge  of  pus  with  the  urine.  The  severity  and 
type  of  the  pain  depend  mainly  upon  the  character  of  the  surgical  cause  of 
the  pyelitis.  Calculi  usually  cause  pain  and  tenderness  to  a  degree  pro- 
portionate to  the  size  of  the  stone.  Pain  is  more  severe  when  the  ureter  is 
occluded  than  when  the  contents  of  the  renal  pelvis  are  permitted  to  escape 
more  or  less  freely.  It  is  also  more  severe  on  movement  where  calculus 
exists.  Attacks  of  nephralgia  or  true  nephritic  colic  are  frequent  when  the 
pyelitis  depends  on  renal  calculus.  Cancer  or  sarcoma  usually  cause  severe 
pain.  Many  cases  of  chronic  jDyelitis  develop  without  any  pain  referable 
to  the  kidney,  the  symptoms  being  apparently  entirely  vesical  and  con- 
sisting of  strangury  and  frequent  micturition.  The  vesical  symptoms  are 
due  to  two  causes,  viz.:  reflex  irritation  of  the  vesical  neck  and  direct  irri- 
tation produced  by  pus  and  detritus — neoplastic  or  calculous — in  the  urine. 
So  prominent  does  the  vesical  irritation  become  in  some  cases,  that  an  error 
in  diagnosis  is  made  and  treatment  instituted  for  cystitis  alone. 

The  urine  is  highly  acid  early  in  the  course  of  pyelitis,  unless  sec- 
ondary to  chronic  bladder  disease,  but  later  on,  if  secondary  cystitis  de- 
velops, it  may  be  ammoniacal.  A  small  amount  of  blood  may  be  present  and 
yield  albumin  to  the  heat  and  nitric-acid  tests.  Under  the  microscope, 
mucus,  blood-corpuscles,  and  the  characteristic  epithelium  of  the  renal 
pelvis  are  first  seen  in  the  simpler  cases,  and  later  on  pus  is  found.  The 
urine  is  not  always  reliable  as  a  means  of  diagnosis,  because  of  its  con- 
tamination by  the  products  of  cystitis,  gonorrhea,  etc. 

When  the  urinary  pus-deposit  of  pyelitis  is  characteristic,  it  forms  a 
thick,  powdery,  greenish  layer 'at  the  bottom  of  the  vessel.  When  pro- 
nounced cystitis  co-exists,  however,  the  pus  occurs  as  is  usual  in  that  dis- 
ease— mainly  in  stringy,  ropy  clots  and  gouts.  If  these  be  decanted  oft',  a 
greenish,  oily  la^^er  is  often  left  behind,  showing  the  co-existence  of  pye- 
litis. Allien  no  cystitic  ropy  clots  are  present  the  pus  is  evenly  disseminated 
throughout  the  urine. 

The  constitutional  s}"mptoms  of  pyelitis  depend  for  their  severity  upon 
the  amount  of  pus  in  the  renal  pelvis.  In  general,  they  are  those  of  ordi- 
nary hectic.  In  some  cases  distinctly  intermittent  chills  occur,  closely 
simulating  malarial  paroxysms:  in  others  no  constitutional  symptoms  ex- 
cept, perhaps,  slight  malaise  are  noticeable.  In  some  rare  cases  of  calculous 
pyelonephritis  pain  will  be  experienced  in  the  loin  corresponding  to  the 
comparativeh'-healthy  kidney,  as  seen  in  a  case  that  will  shortly  be  de- 
scribed. 

Ptoxepheosis. — When  the  exit  of  pyelitic  pus  into  the  ureter  is  ob- 
structed, it  accumulates  in  and  distends  the  renal  pelvis,  forming  the  con- 


PTOITEPHEOSIS.  865 

dition  known  as  pyonephrosis.  This  is  one  of  the  most  important — al- 
though not  the  most  frequent — varieties  of  surgical  kidney.  In  some  cases 
the  entire  renal  pelvis  is  not  involved,  the  pus  having  accumulated  in  a 
sacculus  which  from  time  to  time  bursts,  giving  exit  to  the  pus  into  the 
renal  pelvis  and  thence  into  the  ureter.  This  condition  gives  rise  to  a 
marked  variation  in  the  amount  of  pus  in  the  urine,  the  deposit  at  one 
time  well-nigh  disappearing,  only  to  again  appear  in  large  amount;  this 
variation  is  especially  marked  when  the  condition  is  unilateral.  Quite  often 
only  one  kidney  is  pyonephrotic,  the  other  acting  vicariously  and  being 
sufficient  for  the  elimination  of  waste.  Yery  often  in  cases  of  surgical 
kidney  a  very  thin  layer  of  cortex  seems  to  be  sufficient  to  carry  on  the 
amount  of  elimination  of  urea  and  other  waste-matters  necessary  to  ex- 
istence. 

When  pyonephrosis  develops  certain  special  symptoms  arise,  due  to 
the  mechanic  disturbance  produced  by  the  tumor.  The  bowels  are  quite 
likely  to  be  more  or  less  pressed  upon,  with  consequent  interference  with 
their  functions. 

The  chief  characteristic  of  advanced  pyonephrosis  is  the  presence  of  a 
tumor  in  one  side  of  the  abdomen.  The  structures  of  the  lumbar  region 
are  very  dense  and  resisting;  hence  the  sacculus  can  only  protrude  mainly 
forward  and  slightly  laterally.  Palpation  and  percussion  demonstrate  the 
existence  of  a  tumor  quite  readily,  but  careful  study  of  the  history  of  the 
case  and  aspiration  of  the  contents  of  the  tumor  are  necessary  to  a  positive 
diagnosis.  Tenderness  and  obscure  fluctuation  are  additional  signs,  but  the 
latter  may  be  absent  in  tumors  of  small  or  moderate  size. 

The  general  symptoms  become  very  prominent  in  severe  cases,  hectic 
being  especially  pronounced.  The  patient  is  apt  to  finally  succumb  to  the 
exhaustion  produced  by  prolonged  suppuration,  and  in  very  protracted  and 
exceptional  cases  lardaceous  deposits  may  occur  in  various  organs.  Uremia 
is  a  factor  in  all  severe  cases  of  pyonephrosis.  Its  severity  depends  upon 
the  extent  of  renal  tissue  involved,  disease  of  both  kidneys  being  almost 
certain  to  produce  a  greater  or  less  degree  of  uremia.  A  moderate  amount 
of  uremia  may  perhaps  be  tolerated,  but  when  a  sudden  strain  is  thrown 
upon  the  small  portion  of  renal  tissue  yet  remaining  it  is  apt  to  suspend 
work  altogether,  with  a  consequent  fatal  result. 

The  results  of  pyonephrosis  are  variable.  In  some  cases  the  kidney- 
structure  and  walls  of  the  renal  pelvis  become  enormously  dilated  and  sac- 
culated, perhaps  filling  the  abdomen  almost  completely.  The  walls  of  the 
pus-sac  may  finally  become  so  thin  that  rupture  occurs  at  some  point  and 
the  pus,  decomposing  urine,  and  deposited  sabulous  matter  escape  into  the 
perirenal  cellular  tissue.  This  course  is  especially  apt  to  be  followed  where 
renal  calculus  exists,  for  the  pressure  of  the  stone  is  quite  likely  to  produce 
ulceration  and  rupture  of  the  already  thin  and  weakened  walls  of  the  sac- 
culus. 


866  SUEGICAL   AFFECTIONS    OF    THE    EIDNEY. 

Wlien  the  contents  of  the  renal  pelvis  escape  into  the  surrounding 
tissues,  inflammation  and  abscess  invariably  occur — perinephritic  abscess. 
An  abscess  of  this  kind  usually  burrows  in  different  directions,  and  may 
open  in  the  most  unexpected  and  remote  situations;  thus  it  has  been 
known  to  open  into  the  lungs,  intestine,  and  bladder.  In  the  more  fortu- 
nate and  favorable  cases  it  points  in  the  lumbar  region  or  flank,  where  it  is 
easily  reached  and  evacuated.  Cases  have  been  noted  in  which  the  abscess 
came  to  the  surface  below  Poupart"s  ligament,  following  the  usual  course 
of  psoas-abscess,  for  which  it  is  quite  apt  to  be  mistaken  under  such  cir- 
cumstances. 

When  the  abscess  has  finally  opened  spontaneously  or  has  been  evacu- 
ated, a  fistulous  track  usually  remains  for  an  indefinite  time.  Through  this 
track  urine  as  well  as  pus  may  escape,  and  in  some  cases  small  stones  finally 
become  extruded  or  are  detected  and  extracted.  When  a  stone  exists  in  the 
renal  pelvis  these  fistulas  never  heal  until  the  source  of  irritation  has  been 
removed;  quite  often,  indeed,  nephrectomy  is  necessary,  even  though  no 
stone  be  present,  before  closure  of  the  suppurating  track  will  occur.  In 
some  instances  a  fistula  is  perpetuated  by  sabulous  deposit  along  its  track. 
After  removal  of  this  material  healing  is  sometimes  rapid.  Operation  is 
often  absolutely  necessary  to  save  the  patient  from  death  from  prolonged 
suppuration  and  exhausting  pain.  The  prospect  of  both  surgical  and 
spontaneous  cure  depends  chiefly  upon  the  condition  of  the  opposite  kidney. 
After  evacuation  the  affected  organ  sometimes  becomes  obsolete:  i.e.,  shrivels 
up  and  ceases  to  produce  any  disturbance.  In  such  cases,  if  the  opposite 
kidney  be  comparatively  sound,  complete  restoration  to  health  may  occur. 

Evacuation  of  the  pyonephrotic  abscess  is  not  absolutely  necessary  to 
spontaneous  recovery,  as  shown  by  those  rare  cases  in  which  the  pus  under- 
goes caseation  and  the  morbid  process  ceases.  This  favorable  ending  can- 
not often  occur  in  the  presence  of  stone  or  in  eases  of  double  pyonephrosis. 

It  would  seem  that  perinephritic  abscess  may  be  produced  by  other 
causes  than  stone  or  other  diseases  of  the  renal  pelvis.  Bowditch  has  re- 
corded severaltypic  cases  of  this  kind  attributed  to  cold,  muscular  strain, 
etc.  It  is  probable  that  stone  may  produce  perinephritic  abscess  without 
the  intervention  of  pyonephrosis  or  rupture  of  the  renal  pelvis.  This  would 
seem  to  be  demonstrated  by  the  following  interesting  case  occurring  in  the 
author's  practice: — 

Case. — The  patient  was  a  young  man,  19  years  of  age,  who  had  previously 
been  very  healthy.  Four  weeks  prior  to  the  author's  first  visit  the  youth  was  sud- 
denly awakened  one  morning  by  a  severe  pain  in  the  right  ileo-lumbar  region.  This 
pain  had  been  constant  from  that  time  on,  and  had  been  but  imperfectly  relieved  by 
morphia.  The  urine  was  scanty  and  high-colored,  and  voided  with  severe  strangury 
every  few  minutes.  The  pain  radiated  down  the  thigh  and  groin  of  the  affected  side, 
but  did  not  affect  the  testicle.  The  appetite  had  failed  completely.  There  had  been 
exacerbations  of  pain  from  time  to  time,  with  at  no  time  elevation  of  temperature  or 


PYONEPHROSIS.  867 

rigors.  Such  was  the  history  given  by  the  attending  physician,  by  whom  the  author 
was  called  in  counsel. 

Upon  examination  the  temperature  was  found  to  be  normal,  the  pulse  about  60 
and  feeble.  The  patient  was  still  suffering  with  agonizing  pain  in  the  right  side  and 
right  lumbar  region.  There  was  considerable  prostration.  Pressure  elicited  great 
tenderness  over  the  right  kidney  and  in  the  course  of  the  ureter  both  in  front  and 
behind.  The  liver  was  apparently  normal.  The  urine  contained  no  abnormal  elements, 
but  was  still  scanty  and  high-colored,  micturition  being  frequent  and  painful. 

In  view  of  the  history  and  physical  status  of  the  case  a  diagnosis  of  passing 
renal  calculus  seemed  justifiable,  the  stone  having  in  all  probability  become  impacted 
in  the  upper  portion  of  the  ureter  or  at  the  opening  of  the  renal  pelvis.  This  diagnosis 
was  made  more  probable  later  on  by  the  fact  that,  as  the  patient  expressed  it,  the 
painful  point  had  gradually  descended  toward  the  iliac  fossa. 

The  usual  line  of  treatment  by  free  doses  of  opiates,  diluents,  hydrangea,  and 
the  application  of  hot  poultices  was  continued.  Four  weeks  later  the  author  Avas 
called  to  operate  upon  a  large  abscess  that  was  pointing  in  the  back  at  the  right  of 
the  spine,  midway  between  the  last  rib  and  the  crista  ilii.  Upon  incision  this  gave 
exit  to  about  three  pints  of  healthy-looking  pus.  Upon  exploring  the  cavity  with 
the  finger,  it  was  found  to  enter  the  abdomen  at  the  free  border  of  the  ribs,  extend- 
ing upward  to  the  kidney,  the  lower  portion  of  which  could  be  plainly  felt  free  in 
the  abscess-cavity.  Contrary  to  expectation,  no  stone  or  other  apparent  cause  for 
the  abscess  could  be  found  in  the  discharges  or  on  palpating  the  course  of  the  ureter. 
Under  antiseptic  dressings  the  abscess  healed  perfectly  at  the  end  of  about  five  weeks. 

In  this  case  it  is  probable  that  a  small  stone  descended  from  the  kidney,  and, 
becoming  temporarily  lodged  somewhere  in  the  course  of  the  ureter,  produced  irrita- 
tion in  the  surrounding  cellular  tissue,  either  reflexly  or  directly,  with  associated 
infection  and  consequent  abscess.  The  source  of  pus-infection  would  be  difficult  to 
determine.  No  stone  has  ever  escaped  during  urination  so  far  as  known;  hence 
vesical  calculus  may  develop  sooner  or  later. 

Pyonephrosis  may  be  the  result  of  renal  tuberculosis,  with  or  without 
general  infection.  Even  the  non-tubercular  form  may  eventually  lead  to 
general  tubercular  deposit,  just  as  any  chronic  suppurative  process  may  do. 
An  interesting  case  of  double  calculous  pyonephrosis  was  reported  to  the 
pathologic  society  of  London,  that  the  attending  surgeon  believed  to  have 
some  bearing  upon  the  question  of  so-called  "sympathy"  between  the  kid- 
neys. 

Case. — A  man,  aged  22,  entered  St.  Mary's  Hospital,  London,  in  November,  1886. 
For  ten  years  he  had  suffered  pain  in  the  region  of  the  left  kidney,  with  occasional 
attacks  of  left  renal  colic.  In  1882  he  began  to  pass  gravel  and  to  suffer  from  irrita- 
bility of  the  bladder,  and  in  1885  a  small  calculus  was  removed  by  lateral  lithotomy. 
Symptoms  of  vesical  calculus  soon  recurred,  together  with  pain  in  the  left  loin,  and 
his  general  health  became  much  broken.  His  urine  contained  pus  and  occasionally 
blood.  Left  calculous  pyelonephritis  was  diagnosed  in  addition  to  stone  in  the  bladder, 
and  the  latter  was  accordingly  removed  by  median  incision  on  December  4,  1886.  Ten 
days  later  the  left  kidney  was  exposed  in  the  loin  and  two  small  calculi  were  removed 
from  a  large  suppurating  cyst.  The  amount  of  pus,  however,  did  not  materially 
lessen,  and  toward  the  end  of  January  he  began  to  have  pain  in  the  region  of  the 
right  kidney,  from  which  it  was  soon  suspected  that  the  pus  now  came.  On  February 
18th  he  was  attacked  with  violent  pain  in  the  right  loin,  Avith  rigors,  vomiting,  and 
high  temperature.     At  the  same  time  the  pus  almost  entirely  disappeared,  and  his 


868  SURGICAL    AFFECTIONS    OF    THE    KIDNEY. 

urine  dropped  from  forty-two  to  twenty  ounces.  It  was  believed  that  this  urine  was 
furnished  by  the  left  kidney  only.  The  symptoms  increased  and  there  was  fullness  in 
the  right  loin.  On  February  25th  the  right  kidney  was  exposed;  it  was  found  much 
enlarged  and  surrounded  by  fetid  pus,  and  there  was  an  opening  into  the  pelvis 
from  which  an  abscess  had  probably  burst  into  the  perinephric  tissue.  No  stones 
were  found.  He  did  well  after  this  operation.  The  urine  steadily  increased  in  quan- 
tity, the  pus  diminished,  and  the  pain  ceased.  He  left  the  hospital  on  May  26th, 
and  a  feAV  days  afterward  he  passed  four  small  calculi  per  iirethram.  From  that  time 
he  made  steady  progress  toward  recovery. 

The  case  is  of  interest  from  its  bearing  on  the  question  of  sympathy  between 
the  kidneys,  and  it  was  suggested  that  in  this  case  the  right  kidney  had  in  all 
probability  contained  calculi,  though  without  giving  rise  to  symptoms,  for  some  con- 
siderable time,  and  that  its  condition  was  revealed  by  the  operation  on  its  fellow. 

From  the  theoretic  stand-point  of  the  reporter  this  case  is  valueless. 
As  an  example  of  bilateral  calculo-purulent  renal  disease  it  is  worthy  of 
note.  The  term  sympathy  is  very  far-fetched  in  its  relations  to  this  case, 
which  was  evidently  a  plain,  straight  case  of  double  consecutive  jDyelone- 
phritic  infection  secondary  to  renal  calculus.  It  seems  peculiar  that  medical 
men  are  so  frequently  compelled  to  resort  to  the  meaningless  term,  "sym- 
pathy," in  attempting  the  explanation  of  various  morbid  processes.  With 
our  advanced  ideas  regarding  the  functions  of  the  sympathetic  system,  par- 
ticularly those  functions  that  we  term  trophic,  we  should  be  able  to  account 
for  some  of  these  phenomena  in  a  more  logical  manner.  Eeflex  disturbance 
of  nutrition  suffices  to  explain  many  of  the  so-called  sympathetic  affections; 
infection  explains  the  rest.  The  lines  of  thought  expressed  by  Hilton  in 
his  valuable  little  work,  are  very  instructive  in  this  connection.^ 

The  consistency  of  our  modern  bacteriologic  notions  depends  so  mark- 
edty  upon  a  material  source  of  irritation  that  we  are  apt  to  lose  sight  of 
the  morbid  possibilities  of  purely  nervous  influences,  which,  with  or  without 
superadded  infection,  may  become  of  serious  import. 

Prognosis. — The  prognosis  of  pyelitis  varies  greatly  in  different  cases. 
In  a  general  way  it  depends  upon: — 

1.  Whether  it  is  idiopathic  or  secondary.  2.  The  presence  or  absence 
of  stone.  3.  The  degree  of  freedom  of  drainage  via  the  ureter.  4.  Whether 
the  condition  be  unilateral  or  bilateral.  5.  The  extent  to  which  the  se- 
creting structure  of  the  kidney  is  involved.  6.  The  character  of  the  pri- 
mary disease,  wdiere  the  pyelitis  is  secondary. 

Simple  pyelitis  due  to  exposure  or  secondary  to  curable  bladder,  ure- 
thral, or  prostatic  difficulties  usually  disapjDears.  A  cure  is  necessarily  im- 
possible in  many  cases  until  after  all  primary  obstructive  difficulties  have 
been  removed.  Pyelitis  dependent  upon  acute  fevers,  especially  the  exan- 
themata, does  not  per  se  destroy  life,  but  recovers  spontaneously  as  soon  as 
the  general  disease  subsides,  or  shortly  thereafter. 


^"Rest  and  Pain." 


TREAT:ME]SrT    OF    PYELITIS    AND    PYONEPHROSIS.  869 

Pyelitis  secondary  to  cancer,  tumors  of  various  kinds,  and  tubercular 
disease  is  never  recovered  from. 

Calculous  pyelitis  may  subside  if  the  stone  is  removed,  but  will  persist 
as  long  as  the  foreign  body  is  present.  When  both  kidneys  are  involved  a 
fatal  result  occurs  sooner  or  later  in  almost  all  cases. 

Pyonephrosis  was  formerly  inevitably  fatal  in  the  majority  of  cases  and 
even  with  our  modern  surgical  treatment  double  simultaneous  pyonephrosis 
cannot  be  cured.  In  some  happy  instances  in  which  one  kidney  is  com- 
paratively sound  a  pyonephrotic  kidney  may  undergo  spontaneous  cure. 
The  occasional  accidental  post-mortem  discovery  of  dried  up  renal  pus-sacs, 
perhaps  containing  calculi,  has  demonstrated  the  possibility  of  spontaneous 
recovery. 

Treatment. — The  general  and  medical  treatment  of  pyelitis  and  pyo- 
nephrosis is  not  very  satisfactory.  Inasmuch  as  inflammation  of  the  pelvis 
of  the  kidney  is  almost  invariably  dependent  upon,  and  secondary  to, 
chronic  disease  of  other  portions  of  the  genito-urinary  tract,  or  to  renal 
or  other  disease  acting  mechanically,  there  are  few  cases  that  can  be  treated 
with  direct  reference  to  the  condition  of  the  renal  pelvis  itself.  Pyelitis 
secondary  to  chronic  cystitis,  renal  or  vesical  calculus,  urethral  stricture, 
hypertrophied  prostate,  or  tumors  producing  obstruction  of  the  genito-uri- 
nary tract  is  necessarily  of  minor  consideration,  treatment  being  directed 
chiefly  toward  the  primary  condition.  The  special  measures  for  the  relief 
of  these  various  conditions  have  been  or  will  be  considered  in  their  proper 
connection.  It  is,  of  course,  necessary  in  all  cases  to  attend  to  the  condition 
of  the  urine,  and  this,  as  a  rule,  requires  neutralization  or  perhaps  alka- 
linization.  The  fact  that  the  urine  is  ammoniacal  as  expelled  from  the 
bladder  does  not  always  contra-indicate  the  administration  of  combinations 
of  alkalies  with  the  vegetable  acids,  for  the  reason  that  the  urine  as  found 
in  the  kidney  is  generally  strongly  acid  and  irritates  the  renal  pelvis.  The 
resultant  mucus  acts  upon  the  vesical  urine  catalytically,  and  develops  am- 
monium carbonate  from  the  urea.  Ammoniacal  decomposition  of  urine  in 
the  bladder  is  a  purely  secondary  affair.  When  pyelitis  has  existed  for  any 
length  of  time  in  cases  in  which  the  primary  cause  of  the  difficulty  is  lo- 
cated in  the  kidney,  the  bladder  must  necessarily  become  affected  second- 
arily, as  a  consequence  of  the  irritation  produced  by  the  purulent  and  acid 
urine  as  it  enters  that  viscus.  The  fact  that  this  urine  decomposes  and  be- 
comes ammoniacal  is  no  criterion  of  its  reaction  as  it  leaves  the  kidney  and 
enters  the  ureter. 

Tonics  are  always  indicated  in  pyelitis,  the  various  preparations  of  iron 
and  codliver-oil  being  the  most  useful.  The  mineral  acids  are  also  of  serv- 
ice in  some  instances.  Malt-extract  in  its  different  forms  constitutes  an 
excellent  tonic  in  some  cases.  The  malt  preparations  containing  the  least 
amount  of  alcohol  are  preferable. 

In  certain  cases  of  pyelitis  dependent  upon  general  affections,  such  as 


870  SUKGICAL   AFFECTIONS    OF    THE    KIDNEY. 

the  exanthematoiis  or  zymotic  fevers  and  scurvy,  and  in  tubercular,  can- 
cerous, and  calculous  disease  of  the  kidney,  there  is  often  a  marked  tend- 
ency to  hematuria.  This  requires  the  administration  of  hemostatic  reme- 
dies, such  as  ergot,  hamamelis,  hydrastis,  tannic  or  gallic  acid,  acetate  of 
lead  (pil.  plumbi  et  opii),  aromatic  sulphuric  acid,  or,  best  of  all,  turpen- 
tine. The  natural  alum-waters  are  of  service  in  this  connection.  There 
are  certain  drugs  that  are  likely  to  prove  directly  beneficial  to  the  inflamed 
mucous  membrane,  the  balsams  and  terebinthinate  preparations  being  the 
best  of  these.  The  white  or  Canada  turpentine  is  sometimes  especially 
useful.  Stimulants  may  be  required,  light  wines  being  preferable  to  the 
heavier  malt  or  stronger  alcoholic  preparations.  There  is  usually  no  special 
harm  and  often  much  benefit  to  be  derived  from  two  or  three  glasses  of 
claret  daily  at  meal-times.  In  most  chronic  cases  a  very  nourishing  diet  is 
required,  the  amount  of  food  being  regulated  chiefly  by  the  patient's 
digestive  capacity,  care  being  taken  to  give  food  that  is  readily  assimilable 
and  to  avoid  giving  more  than  the  capacity  of  the  stomach.  The  prepara- 
tions of  gold  are  well  worth  trial  in  every  form  of  pyelitis,  and  in  the 
author's  experience  have  been  of  special  service  in  a  number  of  instances. 
Barclay's  formulas  alford  a  very  reliable  method  for  the  administration  of 
gold. 

In  idiopathic  pyelitis  the  range  of  remedies  is  limited,  the  balsams, 
guaiacol,  eucalj^ptol,  cantharides,  muriated  tincture  of  iron,  and  gold  com- 
prising about  all  that  are  likely  to  prove  serviceable.  Counter-irritation  over 
the  lumbar  region  by  means  of  blisters,  and  derivation  by  dry  cupping  are  of 
service.  A  change  of  air  and  scene  in  combination  with  physical  rest  are 
often  required.  A  sea-voyage  is  one  of  the  best  means  to  secure  the  de- 
sired change  of  air  with  comparative  rest. 

When  the  patient  is  not  debilitated,  especially  in  cases  of  pyelitis  in 
which  the  primary  cause  is  readily  removable  and  in  idiopathic  pyelitis,  a 
restricted  dietetic  regimen  is  to  be  advised.  A  diet  composed  mainly  of 
large  quantities  of  milk  prepared  in  various  ways  will,  if  persisted  in,  accom- 
plish more  in  the  majority  of  cases  than  any  form  of  medicinal  treatment 
that  could  be  advised. 

In  acute  inflammation  of  the  renal  pelvis  there  are  more  direct  indi- 
cations than  in  the  chronic  form  of  the  disease.  Whenever  during  the 
progress  of  a  case  of  acute  or  chronic  disease  of  the  genito-urinary  tract,  or 
following  an  operation  upon  the  genito-urinar}^  organs,  there  occurs  severe 
pain  in  the  lumbar  region,  sharp  pyrexia,  frequent  and  perhaps  painful  mic- 
turition, the  urine  being  more  or  less  purulent  and  bloody,  active  measures 
of  treatment  are  called  for.  Pilocarpin  should  be  given  hypodermically 
(1)  to  vicariously  relieve  the  kidney,  and  thus,  perhaps,  prevent  extension 
of  the  inflammation  to  the  secretory  structure  of  the  organ;  (2)  to  produce 
general  derivation.  Opium  should  be  given  for  its  anodyne  effect  and  to 
relieve  vesical  sjoasm.     Hot  sitz-baths  and  dry  cups  over  the  kidney,  fol- 


TKEATMENT    OF    PYELITIS   AND    PYONEPHEOSIS.  871 

lowed  later  on  by  a  large  blister  or  hot  poultices  over  the  lumbar  region, 
are  reuuired.  Demulcent  and  diluent  drinks^  such  as  flaxseed  or  slippery- 
elm  tea  in  combination  with  the  citrate  or  acetate  of  potassiu'm  should  be 
given.  Free  and  persistent  saline  catharsis  is  imperatively  indicated  in  these 
cases. 

It  will  be  seen  from  what  has  been  said  that  the  treatment  in  the 
majority  of  cases  of  pyelitis  consists  chiefly  in  palliation.  In  cases  secondary 
to  renal  calculus  nothing  can  be  done  save  to  make  the  patient  as  com- 
fortable as  possible  until  such  time  as  operative  interference  is  deemed  ex- 
pedient. That  internal  remedies  will  be  apt  to  act  upon  the  stone  after 
serious  inflammation  of  the  pelvis  of  the  kidney  has  developed  is,  in  the 
highest  degree,  improbable,  even  though,  as  has  been  indicated  in  the 
solvent  treatment  of  calculus,  something  may  possibly  be  done  in  a  small 
proportion  of  cases  of  simple  renal  stone.  When  the  kidney  becomes  sac- 
culated and  a  tumor  is  perceptible,  incision  or  possibly  excision  of  the 
kidney  should  not  be  delayed.  Where  operative  interference  is  imprac- 
ticable, there  is  nothing  to  do  save  to  continue  the  means  of  palliation  al- 
ready suggested,  with  perhaps,  in  addition,  occasional  aspiration  of  the 
abscess.  In  some  rare  cases  such  a  line  of  treatment  may  eventu.ally  result 
in  renal  atrophy  and  desiccation  of  the  purulent  contents  of  the  sac.  In 
by  far  the  majority  of  cases,  however,  such  a  result  is  not  to  be  hoped  for. 
Opening  or  removing  the  kidney  has,  under  our  modern  system  of  anti- 
sepsis, become  an  established  and  justifiable  surgical  procedure,  and  as  com- 
pared with  many  other  operations, — some  of  which  are  designed  to  relieve 
much  simpler  affections  than  that  under  consideration, — they  are  eminently 
safe. 

It  is  somewhat  surprising  that  the  surgery  of  the  kidney  should  have 
been  so  long  neglected.  It  is,  nevertheless,  a  fact  that  cutting  operations 
upon  the  kidney  are  of  quite  recent  date.  As  an  illustration  of  the  novelty 
of  nephrotomy  up  to  a  comparatively  recent  period,  one  of  Bryant's  cases 
related  in  the  earlier  editions  of  his  surgery  is  suggestive: — 

On  August  31,  1876,  I  cut  down  upon  the  right  loin  of  a  lady,  aged  27,  whom  I 
saw  in  consultation  with  Dr.  Moore  and  Dr.  Pocoek,  of  Brighton,  for  a  swelling  which 
we  diagnosed  as  renal,  and  evacuated  three  pints  of  fetid  pus,  the  lady  making  a  good 
recovery.  In  1877  I  cut  into  the  loin  of  a  man  with  a  lumbar  swelling  and  let  out  a 
quart  of  pus  with  marked  benefit,  my  finger  readily  passing  into  the  dilated  pelvis  of 
the  kidney. 

The  operation  is  not  one  of  difficulty  nor  of  danger.  In  both  these  respects  it  is 
on  a  par  with  lumbar  colotomy,  and  it  is  probable  that  within  a  few  years  it  wiU 
be  as  recognized  an  operation. 

Since  about  the  year  1870  the  surgery  of  the  kidney  has  advanced  by 
rapid  strides,  the  number  of  recorded  operations  being  now  very  large.  The 
first  nephrectomy  was  performed  by  Simon  in  1867. 

Among  the  earlier  contributors  to  the  literature  of  renal  surgery  are 


872  SUEGICAL   AFFECTIONS    OF    THE    KIDNEY. 

the  followiag  oiDerators:  Bowditch/  Peters/  Brant/  A.  Campbell/  Keustis/ 
Wieden/  Gibney/  and  Zweifel.^  Keyes,  Langenbeck,  Parkes,  and  Ash- 
hurst  operated  very  early  in  the  history  of  renal  surgery  and  deserve  great 
credit  therefor.  The  operative  treatment  of  surgical  affections  of  the  kid- 
ney is  now  so  firmly  established  that  citation  of  authorities  is  a  work  of 
supererogation.  The  foregoing  is  simply  a  tribute  to  the  pioneers  in  this 
important  field. 

According  to  the  prevailing  views  based  upon  the  experience  of  our 
most  reliable  modern  surgical  authorities,  it  is  never  justifiable  to  permit 
a  patient  with  a  nephritic  or  perinephritic  abscess  to  die  without  an  effort 
at  relief  by  means  of  nephrotomy  or  nephrectomy.  Should  the  patient 
prior  to  coming  under  observation  become  so  debilitated  that  there  is  little 
probability  of  survival  after  operation,  or  should  both  kidneys  be  involved 
to  a  serious  extent,  the  management  of  the  disease  should  lean  toward  con- 
servatism. It  is  not  only  remarkable  that  operations  upon  the  kidney  for 
the  relief  of  its  various  surgical  diseases  were  not  earlier  practiced,  but  it 
is  little  less  than  astounding  to  the  latter-day  surgeon  that  surgeons  should 
have  had  such  a  horror  of  interference  with  purulent  collections  in  this 
location. 

Nephrotomy  may  be  performed  as  a  preliminary  to  nephrectomy,  the 
propriety  of  immediate  removal  of  the  kidney  being  still  a  matter  of  dis- 
pute among  surgeons.  It  is  considered  best  by  some  to  perform  primary 
nephrotomy  in  perhaps  the  majority  of  cases,  nephrectomy  being  reserved 
for  a  more  advanced  period  in  the  ease.  Tliis  has  been  the  author's  practice. 
Inasmuch  as  simple  incision  and  evacuation  occasionally  results  in  complete 
cure,  it  would  seem  unwise  to  immediately  remove  the  kidney,  especially  in 
view  of  the  fact  that  the  structure  and  function  of  the  opposite  kidney  may 
be  so  impaired  that  removal  of  the  organ  in  question  may  precipitate 
uremia.  The  technic  of  nephrotomy  and  nephrectomy  will  be  considered 
hereafter. 

NEPHEITIS    OF    SUEGICAL    OEIGIN. 

There  are  certain  morbid  changes  occurring  in  the  secretory  structure 
of  the  kidney  in  the  course  of  surgical  affections  of  the  genito-urinary  tract 
that  are  of  great  importance.  These  changes  sometimes  occur  independ- 
ently of  complications  referable  to  the  pelvis  of  the  organ.     They  almost 

^American  Journal  of  the  Medical  Sciences^  1871. 
^New  York  Medical  Journal,  Novemberj  1873. 
^Wiener  medicinische  Wochensehriftj  November,  1873. 
^  Edinburgh  Medical  Journal,  July,   1874. 
°  American  Journal  of  the  Medical  Sciences,  October,  1875. 

*  Deutsches  Archiv  flir  Klinische  Medicin,  November,  1878. 
'  Chicago  Journal  and  Examiner,  June,  1880. 

*  Edinburgh  Medical  Journal,  November,  1879. 


NEPHEITIS    OF    SURGICAL    ORIGIN.  873 

invariably,  however,  exist  as  factors  in  the  ensemble  of  pathologic  changes 
termed  collectively  "surgical  kidney."  Some  of  these  changes  result  from 
obstructive  backward  pressure,  others  from  septic  or  purulent  infection  of 
the  renal  structure,  others  again  from  combined  pressure  and  infection,  and 
still  others  from  the  direct  extension  of  inflammation  in  combination  with 
certain  renal  changes  of  a  purely-reflex  character.  The  pressure-changes 
consist  in  thinning  of  the  cortex  of  the  kidney  associated  with  infiltration 
and  proliferation  of  intertubular  connective  tissue.  Early  in  the  history  of 
the  renal  changes  young  round  connective-tissue  cells  begin  to  choke  up 
the  intertubular  tissue;  this  finally  organizes  and  becomes  fixed  connective 
tissue,  and  presses  not  only  upon  the  blood-vessels,  thus  giving  rise  to  an 
anemic  appearance  of  the  organ,  but  upon  the  renal  tubuli,  interfering 
with  their  function  and  lessening  elimination  of  the  retrograde  products  of 
tissue-metamorphosis.  As  the  process  goes  on,  the  renal  tissue  proper  is 
not  only  atrophied  and  thinned,  but  in  great  measure  absorbed,  so  that 
in  certain  cases  of  hydronephrosis  the  remnant  of  kidney-tissue  is  very 
slight,  the  bulk  of  the  structure  of  the  sac  being  composed  of  a  new  growth 
of  connective  tissue  thrown  out  to  resist  the  strain  incidental  to  urinary 
obstruction.  After  a  time,  as  these  changes  go  on,  the  pyramids  become 
absorbed  to  a  greater  or  less  extent,  the  cortex  in  some  cases  becoming  ex- 
tremely thin.  The  tubules  are  more  or  less  dilated  and  the  epithelium  flat- 
tened. The  morbid  process  may  be  tersely  described  as  one  of  chronic 
interstitial  inflammation  and  atrophy.  Cortical  abscesses  may  co-exist — 
pyelonephritis.  It  is  obvious  from  a  survey  of  the  changes  above  enu- 
merated that  the  thinned  and  atrophied  cortex  is  peculiarly  susceptible  to 
acute  inflammation,  and,  moreover,  that  but  a  slight  degree  of  inflamma- 
tion— or  even  hyperemia — is  sufficient  to  completely  annul  the  secretory 
and  eliminative  functions  of  the  kidney  with  consequent  fatal  uremia.  It 
is  not  necessary  that  direct  irritation  should  occur  in  order  that  acute  in- 
flammation may  be  produced  in  a  kidney  of  this  kind.  Slight  interference 
with  the  bladder  or  urethra  in  cases  of  stone  or  stricture  often  results  in 
reflex  hyperemia  of  the  kidney,  which  in  its  weakened  condition  is  unable 
to  withstand  the  strain.  Even  the  relief  of  obstruction  secured  by  opera- 
tion upon  stricture  and  similar  obstructive  diseases  often  precipitates  renal 
hyperemia  or  even  inflammation — nephritis  ex  vacuo.  Complete  suppres- 
sion of  urine  results  and  the  patient  speedily  dies  in  uremic  convulsions 
or  coma.  It  is  to  be  borne  in  mind  that  the  condition  of  the  kidney  Just 
described  is  apt  to  exist  in  any  case  of  chronic  inflammation  or  obstructive 
disease  of  the  genito-urinary  tract.  This  should  admonish  the  surgeon  to 
be  cautious  in  operations  upon  and  manipulations  of  these  parts,  and  should 
also  impress  him  with  the  necessity  of  accurate  knowledge  of  the  condition 
of  the  urine  in  all  cases  of  genito-urinary  disease.  The  existence  of  such 
a  condition  of  the  kidney  explains  some  of  those  mysterious  cases  of  sudden 
death  after  the  simple  passage  of  a  smooth  steel  sound  into  the  urethra. 


874  SUEGICAL    AFFECTIOXS    OF    THE    KIDX'EY. 

Symptoms. — The  symptoms  of  chronic  renal  disease  occurring  in  the 
course  of  surgical  affections  of  the  genito-urinary  tract  are  not  always  plain, 
and  are  in  many  cases  separable  with  difficulty  from  those  produced  by  the 
diseases  to  which  the  renal  complication  is  secondary.  This  is  especially 
true  of  the  characters  of  the  urine.  In  the  chronic  form  of  interstitial 
nephritis  without  complicating  pus-infection  there  is  usually  some  increase 
in  the  quantity  of  urine  with  a  marked  diminution  in  its  specific  gravity. 
Erichsen  mentions  a  case  in  which  the  patient  passed  nearly  three  quarts  of 
urine  daily,  the  specific  gravity  of  which  was  less  than  1004.  This  pecul- 
iarity of  the  urine,  however,  occurs  in  other  conditions.  The  author  has 
under  treatment  a  young  man,  28  years  of  age,  with  symptoms  of  nephro- 
lithiasis who,  imder  the  influence  of  free  ingestion  of  distilled  water,  has 
passed  nearly  four  quarts  of  urine  per  diem  for  four  months,  of  a  specific 
gravity  of  1000  to  1005.  In  order  to  determine  approximately  the  condi- 
tion of  the  kidney  in  such  cases  it  is  necessary  to  collect  and  examine  the 
entire  quantity  of  urine  j^assed  during  the  twenty-four  hours.  In  cases  of 
this  kind  there  is  little  or  no  albumin,  very  few  casts,  and  frequently  no 
epithelium.  Uremia  may  or  may  not  be  manifest  and  is  apt  to  be  masked 
by  a  greater  or  less  degree  of  toxemia  from  the  infected  bladder  or  urethra 
or  both.    Dry,  sallow  skin,  headache,  and  more  or  less  emaciation  are  usual. 

Acute  Diffuse  Interstitial  Suppurative  Nephritis  of  Surgical 
Origin — Acute  Pyelonephritis. — This  type  of  renal  inflammation  may 
occur  at  any  time  in  the  course  of  surgical  diseases  of  the  genito-urinary 
tract.  In  some  instances  it  is  a  simple  transition  from  the  chronic  form 
already  described,  due  to  various  causes;  in  others  it  is  ingrafted  upon  sim- 
ple reflex  hyperemia  and  irritation.  In  still  others  it  is  the  result  of  direct 
irritation  produced  by  pyelitis  or  by  the  absorption  of  septic  products  or 
pus-cocci  from  the  renal  pelvis. 

Etiology. — The  predisposing  cause  of  the  diffuse  nephritis  is  some  in- 
fective or  obstructive  disease  of  the  genito-urinary  tract.  The  exciting 
causes  of  the  affection  may  be  exposure  to  cold  and  wet,  a  prolonged  de- 
bauch, operations  upon  the  genito-urinary  tract,  or,  more  important  still, 
the  anesthesia  necessitated  by  such  operations,  ether  being  most  dangerous. 

Morbid  Anatomy. — The  kidney  becomes  soft  and  swelled,  its  surface 
becomes  mottled  and  the  proper  renal  capsule  opaque  and  vascular.  The 
capsule  is  normally  easily  separable  from  the  renal  substance,  but  is  now 
more  or  less  adherent  and  small  particles  of  the  soft  and  pulpy  kidney- 
tissue  adhere  to  it  when  torn  away.  The  surface  of  the  kidney  presents  a 
peculiar  purplish,  mottled  appearance,  and  the  "stars  of  Verheyn'^  are  in- 
jected and  prominent.  Small  3'ellowish  spots  are  sometimes  visible  to  the 
naked  eye,  these  parts  being  soft,  and,  in  a  more  advanced  stage  of  the 
process,  undergoing  transition  into  small  abscesses  under  the  influence  of 
pus-microbes:  acute.  pyeloneiDhritis.  The  epithelium  of  the  kidney  is 
swollen,  granular,  and  easily  detached.     In  some  instances  small  hemor- 


NEPHEITIS    OF    SUEGICAL    OEIGIN.  875 

rhagic  points  are  visible  in  various  portions  of  the  cortex.  Interstitial  ab- 
scesses rarely  occur  in  the  course  of  acute  interstitial  inflammation,  and  then 
only  in  connection  with  pyelitis  or  general  pus-infection,  pyogenic  sep- 
ticemia, or  pyemia.  In  fact,  in  all  cases  the  purulent  process  is  probably 
dependent  upon  sejosis,  the  condition  in  pyemia  being  embolic,  and  in  sup- 
purative pyelitis  one  of  direct  infection  by  the  products  of  putrefaction 
plus  the  streptococcus  lyyogenes.  There  is  a  difference  in  the  appearance 
of  the  abscesses  produced  by  acute  suppurative  nephritis  dependent  upon 
pyelitis — pyelonephritis — and  those  due  to  pyemic  emboli.  The  latter  are 
wedge-shaped,  limited  to  the  periphery  of  the  organ,  and  surrounded  or 
accompanied  by  hemorrhagic  infarcts;  the  former  are  more  or  less  rounded 
or  irregular  in  form. 

Symptoms. — Acute  renal  inflammation,  with  or  without  suppuration, 
announces  itself  in  a  very  decided  manner.  A  marked  chill  usually  first 
occurs,  this  being  succeeded  by  sweating.  The  temperature  often  rises  to 
a  high  point,  105°  or  106°  F.  being  not  unusual.  The  fever  soon  subsides, 
but  the  temperature  does  not  reach  the  normal  standard.  There  may  be  a 
recurrence  of  chill  and  sweating;  the  tongue  becomes  dry,  red,  and  cracked; 
appetite  is  lost,  and  the  patient  speedily  emaciates.  Nausea,  vomiting,  and 
diarrhea  are  frequent;  the  patient  soon  sinks  into  a  typhoid  condition  that 
eventually  merges  into  coma,  not  unlike  narcotism.  When  coma  sets  in  the 
temperature  subsides  to  or  below  normal.  Delirium  and  convulsions  are 
occasional.  The  urine  is  usually  suppressed;  the  presence  of  albumin  is  of 
no  special  importance  because  of  the  fact  that  it  has  usually  been  present 
in  the  urine  prior  to  the  occurrence  of  the  acute  inflammation.  Its  presence 
depends  upon  an  admixture  of  blood  and  pus.  Cases  of  this  kind  constitute 
one  of  the  varieties  of  so-called  urine-fever. 

Subacute  Nephritis  of  Suegical  Oeigin. — Another  type  of  renal 
disease,  secondary  to  chronic  obstructive  disease  of  the  urinary  tract,  and 
only  to  be  absolutely  distinguished  from  the  chronic  form  on  the  post- 
mortem table  in  a  certain  proportion  of  cases,  is  best  described  as  subacute 
nephritis  of  surgical  origin.  In  the  chronic  form  Just  described  backward 
pressure  plays  the  principal  role,  infection  being  subordinate  to  it.  The 
reverse  is  true  in  the  subacute  variety,  though  the  urine  may  be  the  same 
in  its  physical  and  chemic  characters  as  in  the  chronic  form.  The  condi- 
tion of  the  bladder  and  renal  pelvis  has  much  to  do  with  the  appearance 
and  character  of  the  urine.  The  products  of  mucous  infection  and  inflam- 
mation are  mixed  with  those  dependent  upon  the  nephritis  per  s&. 

This  subacute  condition  of  inflammation  lasts  indefinitely,  being  asso- 
ciated with  more  or  less  uremia,  often  with  mental  sj^mptoms  such  as  mel- 
ancholia, hypochondriasis,  or  even  mild  psychic  aberration,  perhaps  de- 
lirium, and  unless  the  primal  condition  of  disease  be  removed,  finally  wears 
the  patient  out.  In  most  cases  acute  interstitial  inflammation  supervenes — 
possibly  with  suppuration — and  proves  fatal,  perhaps  very  speedily.     In 


876 


SURGICAL   ATFECTICXS    OF    THE    KIDXEY. 


all  cases  in  Avliicli  the  general  symptoms  lead  ns  to  suspect  subacute  renal 
disease^  it  is  necessary  to  await  tlieir  subsidence  before  undertaking  any 
surgical  operation;  in  fact,  it  is  unwise  to  attempt  even  tlie  simple  passage 
of  a  sound  while  the  patient  is  in  this  condition. 

'\\nien  the.  obstructive  and  infective  condition  originally  causing  sur- 
gical nephritis  is  removed,  the  kidney  may  so  far  recover  itself  as  to  per- 
mit of  fairly  good  health.  It  is  never  the  same  kidney  as  before  it  became 
diseased,  however,  and  comparatively  slight  exciting  causes  may  at  any  time 
jDroduce  acute  renal  congestion  or  inflammation  that  may  prove  fatal.  When 
urinary  obstruction  is  suddenly  removed,  as  by  operation,  acute  nephritis 
is  liable  to  supervene,  either  immediately  or  within  a  few  days  or  weeks, 
and  prove  fatal. 

A  recent  case  of  the  author's  is  a  most  striking  illustration  of  the  dan- 
gers to  which  patients  with  chronic  obstructive  disease  of  the  urinary  tract 
are  subjected,  even  though  the  obstruction  may  have  been  removed: — 


Fig.  200. — Histology  of  acute  interstitial  nephritis  with  disseminated  abscesses. 


Case.— A  gentleman,  62  years  of  age,  had  suffered  from  deep  organic  stricture 
for  many  years.  Some  twelve  years  before  consulting  the  author  an  unsuccessful 
attempt  to  pass  an  instrument  was  made.  Since  then  there  had  been  no  treatment. 
At  the  time  of  examination  it  was  found  to  be  impossible  to  pass  a  filiform,  and 
scA^eral  false  passages  were  discoA'ered.  The  stream  of  urine  was  extremely  small,  and 
micturition  required  considerable  time.  There  was  marked  cystitis,  evidences  of 
which  were  present  in  the  urine.  The  filtered  urine  contained  a  email  quantity  of 
albumin,  but  no  casts.  There  was  slight  chronic  urinary  fever.'  Perineal  section  was 
advised  as  safer  than  repeated  attempts  at  dilation.  After  several  weeks'  careful 
preparatory  treatment  the  urine  became  normal.  Perineal  section  without  a  guide 
was  performed,  it  being  impossible  to  pass  a  filiform  even  under  an  anesthetic.  The 
operation  was  Avithout  incident,  and  healing  of  the  Avound  Avas  prompt,  though  a  small 
fistula  remained  for  some  time.  At  the  end  of  three  Aveeks  he  was  sitting  up  and  dis- 
cussing the  probable  time  of  his  departure  for  home,  Avhen  he  began  complaining  of 
headache,  and  albumin  reappeared  in  the  urine.  A  few  days  later,  almost  complete 
suppression  occurred,  the  quantity  of  urine  falling  as  Ioav  as  six  ounces  in  the  tAventy- 
four  hours.  Vigorous  measures  apparently  succeeded  in  restoring  the  function  of  the 
kidney,  but  acute  mania  dcA-eloped,  and  the  patient  finally  became  to  all  appearances 
hopelessly  insane.    The  urine  maintained  its  improvement.    At  the  end  of  four  months 


NEPHEITIS    OF    SURGICAL    OEIGIN.  877 

brain  improvement  began,  and  one  month  later  the  patient's  mind  was  completely 
restored.  His  general  health  is  now  excellent,  and  his  urinary  functions  are  naturally 
performed. 

Teeatment. — The  treatment  of  the  renal  complications  secondary  to 
surgical  diseases  of  the  genito-urinary  tract  is  involved  in  the  general  and 
special  management  of  the  primary  affection;  it  comprises  chiefly  attention 
to  vicarious  elimination  of  urea;  the  lessening  of  strain  upon  the  kidney 
by  regulation  of  the  diet  and  habits;  the  avoidance  of  rough  and  ill-timed 
manipulations  of  the  urinary  apparatus,  and  the  prevention  of  chill  from 
exposure.  The  management  of  acute  interstitial  inflammation  is  embraced 
under  the  head  of  the  renal  or  uremic  form  of  urine-fever  in  the  chapter 
on  that  subject. 


CHAPTEK  XXXYII. 
SrsGiCAi  ArpEcnoxs  or  the  EIidxet  (Co^s'TixrED). 

CYSTIC  DISEASE,  HYDATIDS,  TTIBEBCULOSIS.  CAKCIX03JA.  SAECOilA,  AND 
SYPHILIS   OE   THE   XIDXEY. 

XEPHBOMTHOTOMY,   XEPHEOTOiTT.    XEPHEECTOMY,   AXD 
XEPHEOPiPtAPHY. 

EEXAL    CYSTS. 

Cystic  kidnev  implies  either  dilation  of  the  organ  as  a  whole,  its 
contents  being  chiefly  urine  or  modified  "uxine.  or  the  formation  of  circum- 
scribed collections  of  fluid  approximating  in  its  characters  normal  or  patho- 
logic iirine  in  Tarious  portions  of  the  renal  stnictnTe.  When  the  wall  of 
the  cyst  is  composed  of  the  secretory  stnictnre  and  pelvis  of  the  kidney  as 
a  whole,  it  is  termed  Jiy drone phrosis.  the  condition  being  from  a  mechanic 
stand-point  essentially  the  same  as  in  pyonephrosis,  the  only  difference 
being  in  the  contents  of  the  sac. 

Etiology. — The  eanses  of  cystic  kidney  may  be  entirely  local,  or  may 
consist  of  some  peculiar  local  condition  dependent  npon  diathetic  influences. 
Again,  although  local  primarily,  the  importance  of  cystic  kidney  may  be 
quite  overshadowed  by  associated  or  resultant  systemic  states. 

1.  Congenital  causes:  (a)  Movable  or  floating  kidney,  with  consequent 
torsion  or  kinking  of  the  ureter,  (b)  Hydronephrosis  from  congenital  con- 
traction, angularity,  valTular  obstruction,  or  atresia  of  the  ureter,  (c)  Der- 
moid cysts,  {d)  Congenital  degeneration  of  glomeruli.  (Danforth.)  (e) 
Imperfect  embryonal  development. 

2.  Constitutional  causes  involving:  {a)  Excessive  formation  or  deposit 
of  the  solid  elements  of  the  urine.  (6)  Tuberculosis,  (c)  Sarcoma,  {d) 
Carcinoma.  Heredity  comes  into  play  in  the  constitutional  phases  of  the 
etiology  of  renal  cysts. 

3.  Mechanic  obstruction  of  the  ureter  due  to  inflammatory  pressure  or 
adhesions  about  the  ureter. 

4.  Inflammation  or  tumors  of  the  pelvic  organs. 

5.  Traumatisms,  involving  the  tubuli  urinifer%  renal  pelvis,  or,  more 
especially,  the  ureter. 

6.  Pathogenic  cysts:    (a)  hydatid:    (I)  cystic  degeneration. 
It  is  unnecessary  to  enter  minutely  into  the  consideration  of  these 

numerous  causes,  it  being  merely  necessary  to  call  attention  to  them. 
The  kidney  may  be  converted  into  a  single  large  hydronephrotic  sac, 
(878) 


CYSTIC    KIDXEY. 


8T9 


or,  through,  occlusion  of  the  renal  tubuli,  it  may  become  a  mass  of  small 
cysts.  In  some  cases  of  hydronephrosis  there  exist,  in  addition  to  the  large 
sacculus,  subcysts,  or  saceuli,  produced  by  dilation  of  the  calices  of  the 
kidney  or  occlusion  of  the  renal  tubules.  As  a  result  of  maldevelopment 
and  degeneration  of  the  kidneys  during  fetal  life,  children  are  sometimes 
born  with  renal  cysts  of  considerable  size,  these  being  usually  conglomerate 
or  polycystic  in  character.  Injuries  to  the  kidney  may  result  in  the 
formation  of  cysts,  either  through  occlusion  of  the  ureter  or  as  a  con- 
sequence of  an  accumulation  of  hemorrhagic  effusion  in  the  substance  of 
the  kidney  that  becomes  subsequently  absorbed  and  replaced  by  watery 
fluid.    Dermoid  and  hydatid  cysts  are  very  rare.    When,  as  a  consequence  of 


Fig.   201. — Hydronephrotic   kidney   without  much   enlargement. 
(After  Moullin.) 


obstruction  of  the  ureter,  urine  accumulates  in  the  pelvis  of  the  kidney,  dis- 
tension of  this  structure  with  atrophy  of  the  substance  of  the  organ  neces- 
sarily occurs,  the  condition  of  the  cortex  constituting  what  has  already  been 
described  as  chronic  interstitial  nephritis,  there  being,  however,  a  pre- 
ponderance of  atrophy  of  the  kidney-substance  as  compared  with  those 
cases  of  renal  disturbance  secondary  to  moderate  obstruction  to  the  urinary 
outflow.  The  hydronephrotic  kidney  may  continue  to  enlarge  almost  in- 
definitely, attaining  an  enormous  size  in  some  cases:  so  large  has  it  become 
in  some  instances  that  it  has  been  mistaken  for  peritoneal  dropsy  and 
ovarian  cyst.  A  case  is  related  by  Eoberts  in  which  something  like  thirty 
gallons  of  fluid  were  removed  post-mortem  from  an  hydronephrotic  kid- 


880  SUEGICAL    AFFECTI0X5    OF    THE    KIDXET. 

nev,  supposed  to  be  of  congenital  origin.  "WTien  hydroneplirosis  is  nni- 
lateralj  complete  absorption  of  the  cortex  of  the  kidney  may  occur,  the 
remaining  kidney  being  sufficient  to  carry  on  the  necessary  elimination  of 
urea.  In  some  cases  in  which  both  kidnej's  are  affected  a  very  small  pro- 
portion of  secreting  renal  tissue  seems  to  be  sufficient  to  carry  on  the 
amount  of  elimination  necessary  to  life.  This  is  probably  due'  to  the  con- 
servatiTe  circumstance  that  the  condition  has  developed  gradually.  The 
system  has  become  accustomed  to  imperfect  elimination  of  urea,  and  vicari- 
ous elimination  has  come  to  the  rescue,  there  being,  moreover,  a  much 
larger  amount  of  urine  secreted  than  by  the  normal  kidney,  albeit  the  urine 
is  of  low  specific  gravity.  The  sum-total  of  solids  excreted  is  therefore 
sufficient  for  the  ordinary  eliminative  necessities  of  the  individual.  A  pa- 
tient with  both  kidneys  in  this  condition  may  survive  for  an  incredibly  long 
time  and  be  comparatively  little  the  worse  for  wear.  Let  him,  however, 
be  subjected  to  operation,  exposure,  or  the  effects  of  alcohol,  and  he  may 
die  very  speedily,  with  symptoms  of  acute  renal  inflammation. 

Hydronephrotic  fluid  is  generally  very  pale,  odorless,  and  of  a  decidedly 
watery  appearance.  It  contaias  no  albumin,  and  is  of  low  specific  gravity. 
In  the  case  mentioned  by  Eoberts  the  fluid  was  of  a  light-brown,  or  coffee, 
color.  The  various  morbid  changes  that  occur  in  typic  surgical  kidney  are 
very  well  illustrated  by  the  following  case  of  hydronephrosis  recorded  by 
Eriehsen^ : — 

Case. — A  case  lately  occurred  at  Unirersity  College  Hospital  whicli  afforded  an 
opportunity  of  examing  the  uncomplicated  effects  of  pressure  with  great  advantage. 
The  ureters  had  been  pressed  upon  bv  two  enormous  sacculi,  which  projected  from 
the  bladder  immediately  behind  the  trigone.  The  bladder  was  much  dilated  and 
hypertrophied,  but  the  cause  of  disease  was  uncertain.  There  were  no  signs  of  old 
or  recent  cystitis,  and  no  instrument  had  been  passed  during  life.  In  this  case 
both  ureters  were  greatly  dilated,  and  the  pelvis  on  each  side  was  expanded  so  as  to 
contain  many  ounces  of  fluid.  The  kidneys  were  somewhat  increased  in  size,  and 
before  being  opened  felt  like  great  thick-walled  bags  of  fluid,  giving  all  over  a  distinct 
sense  of  fluctuation.  On  being  cut  open  each  presented  the  following  appearances: 
The  capsule  was  tough  and  opaque,  and  separated  with  difficulty  from  the  kidney- 
substance,  slightly  tearing  it  in  so  doing,  and  leaving  the  surface  coarse  and  irregular. 
The  surface  was  uniformly  pale,  and  whitish  in  color.  Xo  trace  of  the  pyramids  was 
to  be  seen,  but  where  each  shotild  have  been  was  a  deep  hollow  lined  with  a  smooth 
membrane  continuous  with  the  pelvis  of  the  kidney.  The  cortex  was  of  about  normal 
thickness,  but  in  some  parts  thinner  than  natural:  it  was  somewhat  tough  in  con- 
sistence, and  presented  a  uniform  opaque-whitish  tint.  The  whole  kidney  was  thus 
converted  into  a  great  sacculated  bag,  composed  on  one  side  of  the  dilated  and  thick- 
ened pelvis,  and  on  the  other  of  the  expanded  cortex  of  the  kidney. 

There  were  no  signs  of  past  or  present  acute  inflammation.  On  microscopic 
examination  of  a  thin  section  of  the  cortex  the  chief  change  noticeable  was  an 
abundant  small  round-cell  infiltration  of  the  intertubular  tissue  of  the  kidney. 
Every  tubule  was  separated  from  its  neighbors  by  rapidly-growing  young  connective 


'Science  and  Art  of  Surgerv." 


CYSTIC    KIDNEY.  881 

tissue,  crowded  with  small  round  cells,  and  this,  by  pressing  on  the  vessels,  had 
given  rise  to  the  pale  color  above  noted.  The  new  growth  was  most  abundant  around 
the  Malpighian  bodies,  the  capsules  of  which  were  greatly  thickened;  so  much  so, 
that  in  many  the  vessels  had  been  strangled  and  obliterated.  The  amount  of  change 
was  not  uniform,  the  new  growth  being  more  abundant  in  some  parts  than  in  others. 
The  tubules  themselves  showed  no  great  signs  of  change.  They  were  slightly  dilated 
in  some  parts,  and  the  epithelium  looked  as  if  flattened  by  pressure,  but  in  other 
respects  it  was  perfectly  healthy. 

This  case  shows  that  uncomplicated  tension  from  partial  obstruction  of  the 
ureter  gives  rise  to  a  gradual  absorption  of  the  pyramids,  and  to  a  condition  of 
interstitial  inflammation  of  the  kidney,  probably  varying  in  severity  with  the  degree 
and  acuteness  of  the  obstruction.  In  more  extreme  cases  than  that  above  described 
the  atrophy  of  the  cortex  becomes  much  more  advanced  till  nothing  may  be  left  but 
a  layer  of  kidney-substance,  not  thicker  than  a  shilling.  The  microscope  also  shows 
more  dilation  of  the  tubules  and  flattening  of  the  epithelium.  It  is  an  interesting 
fact  to  be  noted  that  in  the  case  above  described  the  secretion  of  urine  was  abimdant, 
its  specific  gravity  was  1009,  and  it  was  free  from  albumin  and  casts.  It  is  also 
evident  that,  if  such  a  kidney  as  this  were  exposed  to  any  additional  source  of  irrita- 
tion, more  acute  inflammation,  incompatible  with  life,  would  readily  be  set  up. 

Had  pus-infection  with  resulting  suppurative  pyelitis  occurred  in  tins 
case,  pyonephrosis  would  have  resulted.  The  presence  of  kidney-stone 
would  in  such  a  case  quite  likely  determine  the  occurrence  of  pyonephrosis. 
The  sudden  removal  of  pressure  would  inevitably  have  proved  fatal. 

The  collateral  changes  in  the  secretory  renal  structure  are  the  same  in 
all  cases  in  which  similar  mechanic  conditions  prevail.  The  presence  of  a 
calculus  and  pus  in  the  renal  pelvis,  with  an  opening  into  the  surrounding 
tissues  and  consequent  secondary  perinephritic  abscess,  are  all  that  is  neces- 
sary to  complete  the  picture  of  morbid  possibilities  in  the  typic  surgical 
kidney. 

It  is  remarkable  that  rupture  of  an  hydronephrotic  cyst  is  excessively 
rare  in  the  absence  of  trauma  or  surgical  interference.  This  is  probably 
due  to  the  slowness  of  development  of  the  cyst  and  compensatory  develop- 
ment of  interstitial  connective  tissue,  as  the  renal  substance  is  gradually 
thinned  and  atrophied  under  pressure.  Should  the  condition  be  unilateral 
and  obstruction  to  the  flow  of  urine  from  the  renal  pelvis  be  removed, — 
either  spontaneously  or  as  a  result  of  surgical  interference, — and  the  cyst 
evacuated,  complete  cure  with  shriveling  of  the  sac  may  occur.  Spencer 
Wells  punctured  a  large  hydronephrotic  kidney  and  employed  drainage; 
two  calculi  subsequently  passed  from  the  kidney  into  the  bladder  and  the 
hydronephrosis  was  recovered  from.  Taylor  reports  a 'case  of  hydronephro- 
sis in  which  rupture  of  the  sac  occurred  with  extravasation  of  urine  into 
the  peritoneal  cavity.  Laparotomy  was  performed,  a  careful  toilet  of  the 
peritoneum  made,  the  margins  of  the  sac  stitched  to  the  lips  of  the  ab- 
dominal wound  and  the  latter  closed,  with  the  result  of  complete  recovery.^ 

^  It  must  be  remembered  that  hydronephrotic  fluid  is  not  so  dangerous  to  the 
peritoneum  as  ordinary  healthy  urine;  it  certainly  is  innocuous  as  compared  with 
infected  urine. 


882  SUEGICAL   AFFECTIONS    OF   THE    EIDNET. 

Symptoms. — The  symptoms  of  cystic  kidney  are  chiefly  of  a  mechanic 
character  and  due  to  pressure  upon  neighhoring  structures.  The  severity 
of  the  symptoms,  therefore,  necessarily  depends  upon  the  dimensions  of  the 
sac,  and  whether  the  condition  is  bilateral.  Tumors  of  small  or  moderate 
size  are  apt  to  remain  undetected  unless  both  kidneys  are  involved,  and 
even  then  they  cannot  be  positively  diagnosed  unless  a  palpable  tumor  has 
formed.  Marked  hydronephrosis  is  evidenced  by  the  existence  of  a  tumor 
in  the  ileo-lumbar  region  extending  forward  into  the  abdomen.  The  ap- 
pearance of  the  tumor  in  one  or  the  other  side  primarily  is  an  important 
point  in  the  diagnosis.  On  percussion  of  the  abdomen  the  large  intestine 
will  be  usually  found  to  cross  in  front  of  the  tumor.  The  tumor  itself 
presents  the  usual  signs  of  dullness  on  percussion  and  fluctuation.  The 
condition  is  usually  painless  unless  a  calculus  be  present  in  the  pelvis  of 
the  kidney  or  ureter,  in  which  case  there  may  be  considerable  pain.  Aside 
from  the  mere  existence  of  a  tumor  there  are  really  no  characteristic  symp- 
toms in  the  majority  of  cases.  Certain  results  of  pressure  are  occasionally! 
evident,  these  being  chiefly  irritability  of  the  bladder,  pain  in  the  abdomeni 
and  loins,  constipation,  disturbance  of  the  digestive  functions,  and  perhaps! 
diarrhea.  Dry  skin,  thirst,  delirium,  headache,  emaciation,  and  othei 
uremic  symptoms  are  likely  to  be  present  if  both  kidneys  are  involvedJ 
There  is  nothing  characteristic,  or,  at  least,  pathognomonic,  about  the  coni 
dition  of  the  urine,  the  low  speciflc  gravity  and  limpid  character  of  that 
fluid  being  the  principal  features.  In  some  cases  there  occurs  from  time 
to  time  a  sudden  and  copious  discharge  of  urine  coincidently  with  a  sud- 
den diminution  in  the  size  of  the  tumor.     This  is  an  unfailing  sign. 

Many  cases  of  cystic  kidney  pass  unnoticed  during  life,  and  are  only 
discovered  accidentally  post-mortem.     It  is  probable  that  cystic  kidney  is 
quite  frequent,  but  as  the  cases  in  which  post-mortems  are  held  are  very 
few  as  compared  with  the  sum-total  of  deaths  from  all  causes,  it  might  be 
erroneously  inferred  that  renal  cysts  are  comparatively  rare.     It  is  by  no 
means  unusual  for  the  pathologist  to  discover  cysts  of  small  or  moderate] 
size  in  connection  with  perfectly  healthy  kidneys,  in  patients  who  have  diedl 
of  various  diseases  to  which  the  renal  cysts  cannot  possibly  be  referred.| 
Cysts  of  this  character  are  filled  with  a  limpid,  watery  fluid  sometimes  ap- 
proximating the  urine  in  composition  and  appearance.     They  are  formed] 
by  simple  occlusion  of  renal  tubuli,  and  very  rarely  attain  a  sufficient  size! 
to  occasion  any  symptoms  during  life.    As  a  rule,  where  cysts  of  this  soi 
exist,  both  kidneys  are  involved.    Cysts  in  connection  with  granular  or  con- 
tracted kidney  (diffuse  interstitial  nephritis,   cirrhotic  kidney)   are   morel 
often  seen  than  otherwise  in  healthy  organs,  although  they  give  rise  to  quite 
as  little  inconvenience.     Extensive  polycystic  degeneration  of  the  kidneysJ 
has  been  seen,  but  is  very  rare,  and  usually,  if  not  always,  affects  both  organs^ 
beingr,  therefore,  inevitably  fatal  by  progressive  impairment  of  the  renal| 
functions  through  pressure-destruction  of  the  renal  tissue.    Inasmuch  as  ex- 


HYDATID    DISEASE    OF    THE    KIDXEY.  883 

tensive  miilticystic  disease  is  usually  congenital,  it  destroys  life  within  a 
comparatively  short  period  after  birth.  In  very  rare  cases,  indeed,  does  the 
disease  occur  during  adult  life. 

The  diagnosis  of  hydronephrosis,  or  large  renal  cyst,  is  determined 
chiefly  by  the  history  of  the  development  of  the  tumor  in  one  or  the 
other  flank,  its  comparatively  painless  and  insensitive  character,  its  slow 
growth  or  congenital  nature,  and  the  presence  of  urinary  constituents  in 
the  aspirated  fluid.  In  doubtful  eases  an  exploratory  incision  is  always 
warrantable,  the  same  rules  being  applicable  in  cases  of  this  kind  as  in 
ovarian  tumor  and  other  surgical  conditions  of  the  abdominal  cavity. 
Fortunately  for  both  surgeon  and  patient,  laparotomy  for  diagnostic  pur- 
poses has  become  an  established  procedure.  It  is  no  longer  necessary  for 
us  to  blindly  speculate  upon  the  possible  or  probable  character  of  abdominal 
growths  and  various  morbid  conditions;  it  is  now  permissible  to  open  the 
abdominal  cavity,  and  by  means  of  exploration  with  the  flnger,  or  even  in- 
spection by  the  eye,  to  determine  the  precise  nature  of  the  disease.  Ex- 
ploration is  eminently  safe  where  the  kidney  is  suspected,  as  the  operation 
may  be  made  extraperitoneally. 

Teeatment. — The  treatment  of  renal  cysts  should  be  rather  conserva- 
tive on  account  of  the  innocuous  character  of  the  disease  in  the  majority 
of  cases.  Occasional  aseptic  palliative  tappings  are  all  that  should  be  re- 
sorted to  in  some  cases.  Tapping,  followed  by  injection  of  such  irritating 
fluids  as  the  tincture  of  iodin,  has  been  known  to  induce  a  cure.  Billroth 
advises  the  use  of  a  50-per-cent.-iodin  solution  for  this  purpose.  Should 
the  sac,  however,  develop  suppurative  inflammation  after  tapping  and  in- 
jection, incision  and  drainage  become  necessary.  As  the  condition  often 
depends  upon  calculus,  nephrotomy  should  be  followed  by  exploration  of 
the  cavity  of  the  sac  with  the  fijiger,  in  the  hope  of  finding  the  obstructing 
object.  With  its  removal,  followed  by  careful  drainage  of  the  sac-cavity,  a 
cure  may  be  accomplished.  In  cases  in  which  conglomerate  cysts  exist,  it 
is  possible  that  nephrectomy  may  be  required,  with  due  consideration  for 
the  condition  or  possible  absence  of  the  other  kidney.  Incision  and  pro- 
longed drainage  are  sufficient  to  effect  a  cure  in  a  certain  proportion  of  cases. 

HYDATID  DISEASE  OE  THE   KIDNEY. 

Eenal  hydatid  disease  is  a  very  rare  affection  in  America,  although, 
like  hydatids  in  other  situations,  it  is  probably  not  infrequent  in  such  coun- 
tries as  Iceland,  in  which  entozoic  affections  are  common  on  account  of 
the  peculiar  habits  of  the  people  and  the  frequency  of  the  Tcenia  ecJiino- 
coccus  in  their  domestic  animals.  As  illustrative  of  the  rarity  of  hydatid 
disease  in  this  country,  Janeway,  during  a  period  of  ten  years'  service  as 
curator  to  Bellevue  Hospital,  met  with  but  three  instances,  and  in  none  of 
these  were  the  hydatid  tumors  of  sutflcient  size  to  produce  anv  injurious 
results.     Two  of  the  cases  of  hydatids  were  found  in  livers  that  had  been 


884  SURGICAL   AFFECTIONS    OF    THE    KIDKEY. 

lacerated  by  injury.  The  disease  occurs  less  commonly  than  hepatic  or  pul- 
monary hydatids^,  but  ranks  next  to  them  in  order  of  frequency.  It  is 
unnecessary  to  enter  here  into  the  minutice  of  the  life-history  and  patho- 
logic results  of  the  echinococcus,  as  the  subject  is  ably  and  exhaustively 
dealt  with  in'  various  works  on  helminthology  and  treatises  on  practical 
medicine.^ 

Eesults  of  Hydatid  Kidney. — These  depend  mainly  upon  the  size 
of  the  tumor.  In  some  cases  inflammation  and  perinephritic  abscess  are 
caused  by  the  pressure  of  the  tumor,  or  by  its  rupture  and  the  discharge 
of  its  contents  into  the  surrounding  cellular  tissue. 

The  vitality  of  the  echinococci  may  be  destroyed  from  unknown 
causes,  with  a  resultant  shriveling  of  the  cyst.  In  some  instances  calcareous 
deposit  in  the  walls  of  the  cyst  may  occur,  the  resulting  tumor  being  of 
small  size  and  remaining  for  an  indefinite  period  without  producing  dis- 
turbance. In  some  cases  both  kidne)^s  are  involved,  but  in  the  majority  of 
instances  the  disease  is  unilateral.  The  tumor  may  become  of  considerable 
size,  a  diameter  of  seven  to  ten  inches  having  been  attained.  It  never 
attains  so  great  a  size  as  hydatid  of  the  liver.  After  a  variable  time  the 
cyst  is  apt  to  rupture,  either  spontaneously  or  as  a  consequence  of  external 
injury.  As  a  rule,  the  rupture  occurs  into  the  pelvis  of  the  kidney,  and  the 
contents  of  the  tumor  are  discharged  with  the  urine.  Instead,  however, 
of  rupturing  into  the  pelvis  of  the  kidney,  the  cyst  may  take  a  less  favorable 
course  and  open  into  the  intestines  or  lung.  Very  rarely,  if  ever,  does  it 
open  into  the  peritoneal  cavity. 

Symptoms. — The  subjective  symptoms  of  hydatid  tumor  are  very  olj- 
scure  and  never  characteristic,  the  physical  characters  of  the  tumor  alone 
being  depended  upon  for  a  diagnosis.  Even  these  may  be  by  no  means  dis- 
tinctive. After  the  tumor  has  attained  sufficient  size  to  press  upon  surround- 
ing parts,  pain  of  a  neuralgic  character  referable  to  the  lumbar  region  de- 
velops, with  perhaps  reflex  symptoms  pointing  to  the  bladder  precisely  the 
'.same  as  those  produced  by  other  non-malignant  tumors.  If  inflammation 
occurs  in  or  about  the  hydatid  sac  Ave  have  symptoms  identic  with  those  pro- 
duced by  perinephritic  abscess.  When  the  tumor  attains  a  sufficient  size  to 
be  perceptible  to  the  touch,  it  will  be  found  to  be  rounded,  smooth,  and 
elastic,  perhaps  fluctuating, — this  sign,  however,  being  more  or  less  obscure, 
— and  it  imparts  to  the  hand  a  peculiar  fremitus,  or  crackling  sensation, 
known  as  the  hydatid  fremitus.  This  is  a  characteristic  physical  sign  of 
hydatid  disease  occurring  in  whatever  situation.  In  its  absence  there  are  no 
physical  signs  discoverable  by  the  eye  or  touch  that  are  indicative  of  hydatid 
cyst.  When  the  contents  of  the  cyst  discharge  into  the  pelvis  of  the  kidney, 
which  may  be  said  to  be  the  natural  course  of  the  disease,  the  booklets  of 
the  echinococci  are  discharged  witli  the  urinary  outflow  and  may  be  found 


^  Graham's  work  on  hydatid  disease  is  a  classic. 


HYDATID    DISEASE    OE    THE    KIDNEY.  885 

in  the  urine  by  careful  microscopic  examination.  Inasmuch  as  the  hydatid 
fremitus  or  vibration  may  not  be  detected,  or  the  surgeon  may  not  be  suffi.- 
ciently  familiar  with  it  to  determine  its  existence,  the  presence  of  hooklets 
in  the  urine  may  be  said  to  be  the  only  positive  sign  of  hydatid  disease  of 
the  kidney  that  is  obtainable  without  direct  exploration  by  a  cutting  oper- 
ation. In  all  forms  of  cystic  tumor  of  the  kidney,  however,  it  is  always 
warrantable  to  make  an  exploratory  puncture  by  means  of  the  aspirator. 
Microscopic  examination  of  the  fluid  withdrawn  may  clear  up  the  diagnosis. 
As  regards  the  diagnosis  of  hydatid  cyst,  Murchison  says^: — 

The  fluid  which  escapes  from  an  hydatid,  even  if  it  contains  no  echinocoeci  or 
shreds  of  striated  hydatid  membrane,  will  reveal  its  nature  with  absolute  certainty. 
If  the  sac  be  not  inflamed,  it  is  limpid  when  running  in  a  stream,  with  a  slight 
opalescence  when  viewed  in  bulk;  it  is  alkaline,  and  has  a  specific  gravity  of  1007 
to  1010;  it  contains  neither  albumin  nor  urea,  but  throws  down  a  copious  white 
precipitate  with  nitrate  of  silver,  owing  to  its  strong  impregnation  with  common  salt. 
These  characters  apply  to  no  other  fluid  in  the  body,  whether  healthy  or  morbid. 
Even  if  the  case  should  turn  out  to  be  an  aneurism  or  cancer,  no  harm  is  likely 
to  result  from  an  exploratory  puncture. 

Treatment.  —  The  treatment  of  hydatid  tumor  is  necessarily  of  a 
strictly  surgical  character  and  should  be  resorted  to  promptly  on  account 
of  several  important  considerations.  In  the  tirst  place,  a  spontaneous  cure 
is  not  to  be  expected  in  the  majority  of  cases,  for,  if  the  tumor  ruptures 
into  the  pelvis  of  the  kidney,  the  ecchinococci  go  on  proliferating  and  the 
disease  is  kept  up  indefinitely.  x\gain,  suppuration,  either  within  the  sac- 
or  external  to  it  in  the  form  of  perinephritic  abscess,  is  likely  to  occur,  and 
even  failing  this  there  must  necessarily  be  more  or  less  destruction  of  renal 
tissue.  Lastly,  the  cyst  may  rupture  in  some  direction  which  will  neces- 
sitate fatal  disease  of  important  organs.  The  necessary  element  in  the 
successful  treatment  of  hydatid  disease  in  any  situation  is  naturally  the 
destruction  of  the  echinocoeci  and  the  mother-cyst.  A  very  successful 
method  of  accomplishing  this  result  is  electrolysis.  This  is  accomplished 
by  the  transmission  of  a  powerful  galvanic  current  through  the  fluid  ht 
the  sac  by  means  of  needles  introduced  into  its  cavity.  Simple  asjiiration 
is  sometimes  successful  in  destroying  the  echinocoeci,  either  by  the  re- 
moval of  the  pabulum  necessary  to  their  subsistence  or  by  producing  a 
certain  amount  of  inflammation  within  the  sac,  which  is  inimical  to  the 
vitality  of  the  parasite.  Should  a  single  aspiration  be  insufficient  the  op- 
eration may  be  repeated,  i^ntiseptic  incision  and  drainage  may  be  resorted 
to  when  aspiration  fails.  During  contraction  and  closure  of  the  sac  anti- 
septic solutions  of  considerable  strength  may  be  used.  Should  suppuration 
of  the  sac  or  perinephritic  cellular  tissue  occur,  free  antiseptic  incision 
is  imperative.  Internal  remedies  are  of  little  or  no  service  in  hydatid  dis- 
ease, although  diuretics  are  recommended  by  some  authorities.    It  has  been 


"Diseases  of  the  Liver." 


886 


SUEGICAL    AFFECTIOXS    OF    THE    KIDXEY. 


recommended  to  partially  remove  the  fluid  and  replace  it  by  antiseptic  and 
irritant  solutions;,  the  tincture  of  iodin  having  the  preference,  as  a  rule. 
After  incision  of  the  kidney-tumor  through  the  loin,  the  walls  of  the  cyst 
should  be  stitched  accurately  to  the  lips  of  the  abdominal  wound. 

EEXAL  TUBERCULOSIS. 

Tuberculosis  of  the  kidney  occurs  in  three  forms:  1.  As  a  miliary 
deposit  in  the  secreting  structure  of  the  organ  secondary  to  general  infec- 
tion with  tubercle  bacilli.  This  form  is  rarely  detected  during  life,  and 
is  of  pathologic  rather  than  clinical  interest,  being  a  part  of  the  general 
tuberciilar  process.    It  occurs  most  usually  in  young  subjects,  and  in  the 


Fig.  202. — Tuberculous  pyelonephritis.     (After  Moullin.) 


majority  of  cases  affects  both  kidneys.  Other  portions  of  the  genito-urinary 
tract  and  different  portions  of  the  sexual  organs  may  be  involved  in  the 
miliary  tubercular  process,  but  also  as  a  part  of  the  general  infection  and 
not  secondary  to  the  renal  disease.  The  tubercular  deposits  affect  chiefly 
the  perivascular  lymph-spaces  of  the  capillary  blood-vessels,  the  p5Tamids 
of  Malpighii,  and  the  glomeruli.  The  patient  is  alwa3'S  destroyed  by  the 
general  tubercular  infection  long  before  the  changes  in  the  kidney  are  suf- 
ficiently marked  to  give  rise  to  symptoms  referable  to  that  organ. 

2.  This  form,  which  is  also  termed  tubercular  pyelonephritis — '^scrof- 
iilous  kidney" — occurs  as  a  consequence  of  tubercular  deposit  beneath  the 
mucous  membrane  of  the  pelvis  of  the  kidney  and  in  the  parench^^ma  of 
the  organ  secondary  to  caseous  or  suppurative  tubercular  processes  in  other 


EENAL   TUBEKCIJLOSIS.  887 

parts  of  the  body.  Thus,  it  may  be  secondary  to  a  caseating  cavity  in  the 
lung  or  a  caseating  lymphatic  abscess.  A  process  that  is  peculiarly  liable 
to  lead  to  infection  of  the  genito-urinary  tract  is  tubercular  or  pseudotuber- 
cular  testis. 

3.  This  variety,  also  a  tubercular  pyelonephritis,  is  a  sub  variety  of  the 
second  form  of  the  disease.  In  this  form  of  tubercular  kidney  the  caseous 
or  tubercular  process  is  secondary  to  suppurative  inflammation  of  the  pelvis 
of  the  organ.  The  bacillus-bearing  products  of  this  suppurative  inflam- 
mation undergo  caseation  and  infect  the  endothelium  of  the  lymphatics  and 
the  perivascular  lymph-spaces,  causing  a  tubercular  deposit  in  the  secreting 
structure  of  the  organ. ^  Infection  also  occurs  by  way  of  the  veins.  This 
caseous  or  tubercular  material  in  the  kidney  eventually  softens,  breaks  down, 
and  forms  cavities  intercommunicating  and  opening  into  the  calices  and 
pelvis  of  the  organ.  This  degenerative  process  closely  resembles  that  of 
pulmonary  phthisis,  and  progresses  until  the  kidney  is  transformed  into  a 
lobulated,  indurated  capsule  within  which  will  be  found  on  section  an 
irregular  suppurating  cavity  with  a  thick,  pus-producing  lining  and  contain- 
ing a  greater  or  less  quantity  of  pus  and  blood  in  various  states  of  disin- 
tegration, and  renal  tubercular  debris  {caseous  nephritis  or  nephrophthisis). 
In  some  instances  true  miliary  tubercle  may  be  found  scattered  throughout 
the  secreting  structure  of  the  organ.  Should  the  ureter  become  obstructed, 
the  kidney  assumes  the  condition  characteristic  of  ordinary  pyonephrosis. 

It  will  be  observed  that  tubercular  nephritis,  or  renal  phthisis,  is  prob- 
ably never  a  primary  affection,  being  always  secondary  to  disease  of  the 
pelvis  of  the  organ  itself,  or  some  more  or  less  intimately  associated  portion 
of  the  genito-urinary  tract,  or  to  tubercular  disease  in  distant  organs.  There 
may  be  in  some  instances  a  development  of  renal  tuberculosis  {caseous 
nephritis)  secondary  to  suppurative  pyelitis,  and,  secondary  to  the  renal 
caseation,  general  tubercular  infection  may  occur.  Cases  of  this  kind  may 
lead  to  the  inference  that  the  renal  tubercle  is  the  primary  process,  whereas 
the  starting-point  of  the  pathologic  cycle  consists  in  ordinary  suppurative 
inflam.mation  of  the  pelvis  of  the  kidney. 

For  reasons  unknown,  renal  tuberculosis  is  very  rare  in  the  female. 

Diagnosis. — The  diagnosis  of  tubercular  kidney  is  not  at  all  clear, 
the  subjective  symptoms  being  precisely  similar  to  those  of  chronic  pyelitis 
or,  in  severe  cases,  nephralgia  or  nephritic  colic.  If  pyonephrosis  develops, 
both  objective  and  subjective  symptoms  are  precisely  similar  to  that  disease 
when  occurring  under  ordinary  circumstances.  The  general  symptoms  of 
hectic,  wasting,  and  rigors  are  perhaps  more  marked  in  tubercular  pyo- 
nephrosis than  in  the  simple  variety,  but  this  alone  is  insufficient  for  a 
diaofnosis. 


^  It  will  be  observed  in  this  connection  that  Buhl's  theory  of  the  rationale  of 
tubercular  infection  is  accepted  as  logical. 


SUEGICAL    AFPECTIOXS    OP    THE    KIDXET. 

The  urine  contains  pus,  more  or  less  blood,  epithelium  from  the  mu- 
cous membrane  of  the  urinar}^  passages,  and  in  some  cases  casts  of  the 
renal  tubuli.  In  some  instances  aggregations  of  caseous  matter  as  large  as 
a  pin^s  head  may  be  detected,  and  perhaps  by  careful  staining  and  examina- 
tion the  bacillus  tuberculosis  may  be  found.  The  presence  in  the  urine  of 
caseous  masses  or  of  tubercle  bacilli  will  at  once  clear  up  the  diagnosis. 

The  ensemble  of  clinical  features  is,  however,  often  such  that  a  diag- 
nosis can  be  readily  made.  For  example,  in  cases  of  cachectic  individuals 
with  phthisic  lungs  or  tubercular  disease  of  the  testes,  prostate,  seminal 
vesicles,  or  bladder,  suppurative  inflammation  of  the  kidney  may  be  in- 
ferred to  be  tubercular.  Test  inoculation  of  rabbits  with  the  purulent  sedi- 
ment of  the  urine  is  often  a  valuable  means  of  diagnosing  tuberculosis  of 
the  urinary  tract. 

The  general  symptoms  consist  of  chronic  hectic  or  urinar}^  fever  with 
loss  of  appetite,  disturbance  of  digestion  and  nausea,  dr}^  tongue,  and  fre- 
quently diarrhea.  If  the  enlarged  irregular  kidney  can  be  felt  in  the  flank 
the  diagnosis  is  aided  to  a  certain  extent,  providing  other  than  tubercular 
causes  of  pyonephrosis  can  be  eliminated. 

Prognosis. — The  prognosis  is  very  unfavorable,  although  it  has  been 
asserted  that  shrunken  and  cicatrized  kidneys  have  been  found  in  cases  in 
which  renal  tuberculosis  was  supposed  to  have  existed.  It  is  probable,  how- 
ever, that  such  cases  are  not  true  renal  phthisis.  As  a  rule,  the  patient 
emaciates,  and  becomes  exhausted  from  pain  and  the  urinary  irritation  of 
secondary  cystitis;  he  becomes  thin  and  emaciated,  and  finally  dies  of 
asthenia,  with  or  without  uremic  symptoms. 

The  duration  of  the  disease  varies  from  two  or  three  months  to  several 
years,  depending  largely  on  the  character  and  importance  of  associated  con- 
ditions. 

Teeatmext. — The  treatment  of  tubercular  kidney  is  necessarily  very 
unsatisfactory.  It  involves  the  management  of  the  general  condition  by 
tonics,  codliver-oil,  guaiacol,  nucleins,  and  change  of  air.  The  Shurly 
Gibbes  method  of  hypodermic  injections  of  iodin  and  chlorid  of  gold  and 
sodium  has  seemed  valuable.  The  Barclay  formulas  of  gold  and  arsenic 
form  a  very  valuable  means  of  administering  gold  per  oreni.  Operative 
measures  are  not  generally  considered  warrantable  if,  as  is  usually  the  case, 
both  kidneys  are  involved.  When,  however,  we  have  reason  to  believe 
that  but  one  is  afi^ected  (1)  from  the  absence  of  tumor  and  pain  upon  the 
opposite  side,  (2)  from  the  fact  that  an  approximately  normal  quantity 
of  urea  is  throAvn  out  in  the  urine,  and  (3)  from  cystoscopic  study  and 
catheterization  of  the  ureters  (in  favorable  cases),  nephrotomy  may  be 
performed.  Nephrectomy  is  not  a  wise  operation  in  view  of  the  doubt  that 
must  necessarily  exist  regarding  the  condition  of  the  opi^osite  organ.  The 
various  measures  for  determining  the  condition  of  the  opposite  kidney  are 
in  a  general  way  unsatisfactory.    It  is  to  be  noted,  however,  that  catheter- 


EEXAL    TUBEKCULOSIS. 


889 


ization  of  the  ureter,  as  recommended  by  Simon  and  Winckel  and  perfected 
"by  Pawlik  and  Kelly,  especially  for  the  diagnosis  of  renal  conditions  in 
women,  is  often  satisfactory.  Ureteral  catheterization  via  the  cystoscope 
is  sometimes  practicable  in  the  male.  If  at  any  time  we  become  satisfied 
that  the  condition  of  the  other  organ  Avill  warrant  so  serious  a  procedure, 
nephrectomy  may  be  performed.  Pyonephrosis  and  perinephritic  abscess 
from  tubercular  disease  are  to  be  treated  in  the  same  manner  as  the  same 
conditions  occurring  under  other  circumstances.  Occasional  cases  of  bi- 
lateral pyonephrotic  kidney  may  arise,  in  which  simple  incision,  curettage, 
and  gauze  drainage  are  warrantable  in  the  hope  of  prolonging  life.  Only 
one  side  should  be  operated  at  a  time,  and  if  the  condition  of  the  first 
kidney  operated  on  justifies  hope  of  restoration  of  its  functional  integ- 
rity to  a  serviceable  degree,  the  other  kidney  may  be  attacked  later. 
After  a  nephrotomy  has  been  performed,  relatively  strong  solutions  of 
antiseptics  may  be  used  for  irrigating  the  cavity  of  the  kidney,  and  pro- 
longed packing  with  iodoform  gauze  employed. 


Fig.  203. — Harris's  device  for  collecting  urine  from  the  ureters  separately. 


To  facilitate  accurate  diagnosis  in  surgical  diseases  of  the  kidney,  and 
especially  to  determine  which  kidney  is  affected  in  unilateral  disease,  M.  L. 
Harris  has  devised  a  most  ingenious  instrument.  By  this  instrument  it  is 
possible  to  determine  the  existence  and  functional  capacity  of  the  opposite 
kidney,  upon  which  the  patient's  life  must  depend  after  removal  of  the 
diseased  organ.     The  description  of  the  instrument  is  as  follows: — 

The  instrument  consists  of  a  double  catheter  (Fig.  203),  each  separate,  but  in- 
closed in  a  common  sheath  resembling  a  single  flattened  tube.  Each  catheter  is 
movable  on  its  longitudinal  axis.  The  sheath  is  nineteen  centimeters  long,  gradu- 
ated on  its  upper  surface.  The  proximal  portion  (in  reference  to  the  patient)  is 
curved.  This  curved  portion  does  not  pass  at  once  into  the  straight  portion,  but  is 
set  on  a  slight  forward  angular  displacement  three  or  four  millimeters  long.  When 
the  flattened  surfaces  of  the  curves  of  the  two  catheters  are  opposed  the  shaft  is 
nearly  round.  The  distal  extremity  of  each  catheter  is  round  and  curved  in  the  same 
plane  as  the  proximal  extremity,  resembling  the  curved  end  of  a  male  sound. 
The  curves  of  the  two  extremities  being  the  same,  the  distal  indicates  the  direction 
of  the  proximal  end.     Near  the  junction  of  the  distal  curve  with  the  straight  portion 


890 


fcCEGICAL   AFFECTIOXS    OF    THE    KIDXEY. 


is  the  small  tube  continued  in  the  line  of  the  straight  portion  and  opening  into  it. 
The  distal  extremity  of  each  catheter  is  connected  by  rubber  tubing  with  a  separate 
glass  vial.  The  corks  are  doubly  perforated,  each  vial  being  connected  by  rubber 
tubing  with  a  rubber  exhaust-bulb  (Fig.  204).  There  is  a  metal  lever  (Fig.  204a) 
with  a  handle  at  one  end,  the  opposite  extremity  being  cur^-ed  and  flattened  laterally. 
This  is  provided  with  a  perforation  near  the  handle,  is  flattened  on  its  sides,  and 
notched  along  its  lower  border.  A  detachable,  cur^-ed,  forked  metal  piece  connects 
the  catheter  with  the  lever  when  in  use.  This  piece  has  a  spiral  spring  that  catches 
in  the  notches  on  the  under  surface  of  the  lever. 

The  instrument  is  used  as  follows:    The  patient  is  placed  in  the  lithotomy  posi- 


Fig.  204. 


Fig.  204a. — Harris's  device  for  collecting  urine  from  the  ureters  separately. 


tion.  The  iastrument,  with  the  flattened  surfaces  in  contact,  so  as  to  form  practically 
a  single  catheter,  is  introduced  into  the  bladder.  The  connecting  piece  is  then  at- 
tached. The  lever  passing  through  the  forked  connecting  piece  is  now  introduced  into 
the  vagina  in  the  female,  the  rectum  in  the  male.  The  fork  holds  it  in  the  midline. 
When  introduced  the  proper  distance,  as  indicated  by  the  perforation  in  the  lever 
coming  opposite  the  perforations  in  the  forked  piece,  the  lever  is  fastened  by  passing 
the  pin  in  the  forked  piece  through  the  perforation  in  the  lever.  The  instrument  is 
now  opened  in  the  bladder  by  slowly  and  gently  rotating  each  catheter  about  its  longi- 
tudinal axis  until  each  jjroximal  end,  as  indicated  by  the  distal  end,  is  directed  out- 
ward and  backward.  The  angle  subtended  posteriorly  by  the  ends  of  the  catheters 
should  be  about  100  to  110  degrees.     They  are  held  in  position  by  the  spiral  spring. 


MALIGXA^'T    XEOPLASMS    OP    THE    EXDXET.  891 

In  opening  in  this  way,  the  end  of  the  lever  within  the  vagina  or  rectum  passes  up 
between  the  ends  of  the  catheters  so  as  to  form,  a  septum,  extending  longitudinally 
along  the  base  of  the  bladder.  The  lever  end  is  held  between  the  diverging  ends  of 
the  catheters  by  the  spiral  spring  catching  in  the  notches  on  the  under  surface  of 
the  lever.  The  end  of  each  catheter  in  the  bladder  now  occupies  the  bottom  of  a 
little  pocket,  the  pockets  being  separated  by  a  perfect  septum,  or  water-shed.  The 
ureters  open,  one  on  either  side  of  the  water-shed,  near  the  base  of  the  declivity,  in 
the  immediate  vicinity  of  the  respective  ends  of  the  catheters.  By  exhausting  the 
bulb  the  urine,  as  it  escapes  from  the  ureters,  is  made  to  enter  the  ends  of  the 
catheters  and  flows  at  once  into  the  vials,  right  and  left,  respectively. 

ilALIGXAXT  ?4"E0PLASiIS   OF   THE   KED^TEY. 

Cancer  and  sarcoma  of  the  kidney  are  usnallT  and  imaToidablj  con- 
founded, clinically,  and  it  is  questionable  whether  their  differentiation  is 
of  great  practical  importance,  inasmuch  as  there  is  little  or  no  difference 
in  the  malignancy  of  the  two  affections,  and  such  distinctions  as  may  exist 
are  microscopic  rather  than  macroscopic  or  clinical. 

Malignant  disease  of  the  kidney  is  an  uncommon  disease,  and  occurs 
in  two  forms,  viz.:  primary,  in  which  the  original  deposit  is  in  the  renal 
structure,  and  secondary,  in  which  the  disease  comes  on  as  a  consequence 
of  renal  infection  by  cancerous  disease  either  in  some  portion  of  the  genito- 
urinary tract  or  sexual  organs — ascending  infection — or  in  some  tissue  more 
or  less  remote.  The  majority  of  eases  of  renal  cancer  occur  in  childhood, 
the  disease  haying  apparently  a  predilection  for  the  male  sex,  this  being 
particularly  true  when  it  occurs  in  adults.  Old  age  is  the  next  most  favor- 
able period  for  renal  cancer,  youth  and  middle  life  enjoying  relative  im- 
munity. 

The  disease  is  almost  always  encephaloid  in  character,  and  may  present 
the  peculiar  and  characteristic  form  of  encephaloid  known  as  fungus  Jiema- 
todes.  When  secondary  to  cancerous  disease  of  remote  organs,  cancer  of  the 
kidney  is  a  part  of  the  general  infection  and  usually  occurs  in  the  form  of 
cancerous  nodules  of  greater  or  less  dimensions  scattered  throughout  the 
substance  of  both  organs.  Cases  of  scirrhus,  colloid,  and  melanotic  cancer 
of  the  kidney  are  considered  unique. 

Cancerous  deposit  occurs  primarily  in  the  cortex  or  secreting  stmctnre 
of  the  organ  and  invades  with  greater  or  less  rapidity  the  remainder  of  its 
texture.  The  deposit  may  begin  as  a  circumscribed  collection  of  cancer- 
cells  or  an  infiltration  of  the  intervascular  tissue.  If  the  disease  is  pri- 
mary— as  is  very  rarely  the  case — secondary  deposits  in  various  other  organs 
of  the  body  are  to  be  looked  for.  Henry  Morris  states  that,  in  30  cases  of 
malignant  renal  disease  found  in  2610  post-mortems,  25  were  secondary  and 
5  primary.^  According  to  Moxon,  cancerous  disease  does  not  begin  in  the 
kidney  proper,  but  in  the  lymphatic  glands  and  other  structiires  that  sur- 
round and  invest  the  organ:   a  very  plausible  view. 

-  Op.  cit. 


892  SURGICAL   AFFECTIOXS    OF    THE    KIDXEY. 

The  tumor  formed  by  cancer  of  the  kidney  may  grow  to  an  immense 
size.  In  one  case  related  by  Eoberts  the  growth  attained  a  weight  of  31 
pounds.  An  excellent  and  oft-reproduced  illustration  of  this  case  may  be 
found  in  Eoberts's' work  on  renal  diseases. 

As  cancer  of  the  kidney  progresses,  the  renal  substance  becomes  en- 
tirely absorbed  and  replaced  by  cancerous  material.  The  soft  cancerous 
substance  is  permeated  by  large  blood-vessels  of  considerable  tenuity,  that 
are  easily  broken,  giving  rise  to  the  hemorrhages  characteristic  of  renal 
cancer.  It  has  been  asserted  that  portions  of  the  cancerous  growth  may 
break  down  and  be  carried  through  the  medium  of  the  blood  in  the  renal 
vein  to  the  heart,  whence  they  are  driven  into  the  general  circulation, 
forming  pulmonary  and  other  infarctions.  Cases  of  this  kind  have  been 
described. 

It  is  very  rare  for  both  kidneys  to  be  affected  simultaneously  in  renal 
cancer. 

The  duration  of  the  disease  in  children  is,  upon  the  average,  from  six 
to  ten  months.  In  the  adult  it  may  last  eighteen  months  or  two  years  or 
more,  two  years  being,  perhaps,  the  average.  By  comparison  with  other 
forms  of  visceral  cancer  it  will  be  found  that  the  renal  variety  is  compara- 
tively slow  in  adults. 

Etiology. — The  causation  of  the  disease  is  similar  in  many  respects  to 
that  of  cancer  in  other  situations.  Injuries  of  the  kidney  seem  to  be  par- 
ticularly apt  to  be  followed  by  the  development  of  cancerous  disease.  In  a 
case  mentioned  by  Morris  that  authority  advances  as  a  probable  cause  renal 
calculi.  The  case  was  one  of  renal  scirrhus  in  a  man  76  years  of  age. 
Floating  kidney  is  markedly  predisposed  to  malignant  degeneration. 

Cohnheim's  old-time  theory  of  the  origin  of  cancer  seems  to  be  particu- 
larly applicable  to  the  renal  form  of  the  disease.  Congenital  deformities  of 
the  genito-urinary  apparatus  are  relatively  frequent,  and  it  is  nothing  unu- 
sual to  find  upon  autopsy  aberrant  forms  of  development  of  the  kidney.  A 
close  resemblance  to  the  fetal  type  of  kidney  is  occasionally  found  in  au- 
topsies on  young  children.  This  tendency  to  the  failure  of  differentiation 
of  the  kidney-structure  in  fetal  life  may  explain  the  occurrence  of  cancer 
in  some  cases.  Cohnheim's  theory  implies  that  the  fundamental  cause  of 
cancer  is  a  persistence  of  the  embryonal  type  of  cells  in  some  portion  of  the 
tissues.  These  cells  have  an  inherent  capacity  of  rapid  development  under 
the  api3lication  of  the  proper  stimulus;  this  stimulus  may  be  afforded  by  a 
relatively  slight  injury.  Cancerous  formations  are  particularly  apt  to  occur 
if  hereditary  predisposition  to  the  disease  exists.  In  inverse  proportion  to 
the  degree  of  differentiation  of  embryonal  cells  is  their  tendency  primarily 
to  proliferation  and  seeondarih^  to  rapid  retrograde  metamorphosis.  Con- 
stitutional infection  by  the  rapidly  proliferating  and  rapidly  degenerating 
cells  occurs  with  great  facility.  In  view  of  the  tender  age  of  some  subjects 
of  renal  cancer — and,  indeed,  it  may  be  congenital — it  is  reasonable  to  sup- 


MALIGKANT    NEOPLASMS    OF    THE    KIDNEY.  893 

pose  that  the  disease  is  the  direct  result  of  the  persistence  of  the  embryonal 
type  of  kidney-cell  formation.  Whether  or  not  an  exciting  cause  is  neces- 
sary for  the  development  of  cancer  in  such  cases  is,  of  course,  difficult  to 
determine. 

The  autlior  has  recently  seen  a  case  of  renal  cancer  that  well  illustrates 
the  early  period  at  which  it  sometimes  occurs: — - 

Case. — The  case  was  that  of  a  delicate  male  infant  whose  mother  had  suffered 
from  an  attack  of  pneumonia  just  before  confinement.  The  child  was  improperly  fed, 
the  quality  of  food  being  poor  and  the  quantity  insufficient  for  its  nourishment. 
When  first  seen  he  was  in  a  marasmic  condition  from  simple  inanition.  Under 
proper  feeding  improvement  occurred,  but  at  about  the  age  of  three  months  the  child 
began  to  cry  incessantly  and  was  evidently  suffering  from  considerable  pain.  Hema- 
turia developed;  the  abdomen  became  swelled  and  tympanitic;  the  stomach  refused 
to  accept  nourishment,  and  in  a  few  days  diarrhea  supervened,  wasting  being  con- 
sequently very  rapid.  In  a  few  days  the  distension  of  the  abdomen  disappeared,  and 
careful  examination  revealed  the  presence  of  a  flat,  lobulated  tumor,  corresponding 
to  the  situation  of  the  left  kidney.  This  occupied  about  one-half  of  the  abdomen,  was 
moderately  movable,  and  presented  the  usual  physical  signs  of  renal  tumor.  After 
a  day  or  two  marked  and  persistent  hematuria  developed.  A  diagnosis  of  renal 
cancer  was  made.  The  child  died  within  two  weeks  after  the  development  of  marked 
symptoms,  but,  unfortunately,  an  autopsy  could  not  be  secured. 

Sarcoma  of  the  kidney  is  most  frequent  in  children,  and  does  not  differ 
essentially  from  renal  cancer  in  its  clinical  history,  course,  and  results. 

Diagnosis. — The  diagnosis  of  renal  malignant  disease  is  quite  obscure 
at  the  beginning,  excepting  in  those  instances  in  which  it  is  a  complicating 
condition  of  the  cancerous  cachexia  from  malignant  disease  occurring  in 
other  situations.  When,  however,  a  tumor  appears,  co-existing  with  abun- 
dant hematuria  occurring  from  time  to  time,  the  disease  is  comparatively 
easy  of  diagnosis.  It  is  impossible,  however,  to  differentiate  sarcoma  and 
cancer.  The  tumor  appears  between  the  free  border  of  the  ribs  and  the 
crest  of  the  ilium  upon  one  side,  and  may  be  felt  anterior  to  the  edge  of 
the  quadratus  lumborum  muscle  early  in  the  course  of  the  case,  if  a  careful 
examination  be  made.  The  growth  enlarges  upward,  forward,  and  down- 
ward— in  short,  in  all  directions — and  in  some  cases  distends  the  entire 
abdomen.  As  is  the  case  with  all  tumors  involving  the  kidney,  the  trans- 
verse, ascending,  or  descending  colon,  as  the  case  may  be,  lies  in  front, 
yielding  the  characteristic  tympanitic  resonance  of  the  large  intestine.  A 
tumor  of  the  abdomen  across  the  front  of  which  the  colon  passes,  and  which 
yields  dullness  in  all  directions  save  where  it  is  crossed  by  the  large  in- 
testine, may  be  inferred  to  be  a  renal  growth,  and  this  inference  may  be 
made  positive  assurance  by  a  careful  study  of  the  history  of  the  case. 

In  addition  to  blood  in  the  urine  the  characteristic  cancer-cells  or  per- 
haps masses  of  cancerous  tissue  may  be  detected:  this  is  very  rare.  In 
some  cases  coagula  or  cancerous  masses  cause  renal  colic  in  passing  through 
the  ureter.    Blood  in  the  urine  in  conjunction  with  a  tumor  of  the  abdomen 


894  SUEGICAL    AFFECTIOXS    OF   THE    KIDNEY. 

is  patliognomonic  of  renal  cancer^  although  Eoberts  has  mentioned  excep- 
tional instances  in  which  an  enormous  enlargement  was  not  attended  by 
hematuria/  Blood  in  the  urine  does  not  occur  at  the  outset  in  all  cases 
of  renal  cancer.  The  case  of  the  infant  just  described  is  an  illustration 
of  this  fact.  Many  do  not  develop  hematuria  at  all.  More  than  50  per 
cent,  of  cases,  however,  have  hematuria  as  a  symptom,  and  the  quantity 
of  blood  is  usually  considerable. 

The  following  case  is  quoted  as  illustrating  the  early  occurrence  of 
hematuria  in  renal  cancer: — 

Case. — A  girl,  5  years  of  age,  who  had  previously  been  well,  suddenly  had  an 
attack  of  hematuria,  the  source  of  which  could  not  be  discovered.  Three  months  later 
a  swelling  appeared  in  the  right  renal  region,  which  was  believed  to  be  due  to  a  ma- 
lignant growth  on  account  of  its  rapid  development.  The  swelling  was  punctured,  and 
the  fluid  withdrawn  was  examined  microscopically.  It  showed  the  characteristic  evi- 
dence of  renal  cancer.  The  tumor  was  estii-pated  by  Bergmann's  method,  an  incision 
being  made  upon  the  anterior  aspect  of  the  abdomen,  the  peritoneal  cavity  being 
avoided.  The  immediate  results  of  the  operation  were  sufficiently  satisfactory;  there 
was  no  evidence  of  shock,  and  after  two  months  the  abdominal  wound  had  completely 
cicatrized.  Eleven  months  later  the  child  died  from  a  recurrence  of  the  disease  in  the 
cicatrix,  with  extensive  metastases  in  the  liver  and  lungs;  the  left  kidney,  however, 
was  entirely  healthy.  The  author  suggests  that  one  should  always  bear  in  mind  the 
possibility  of  the  presence  of  a  malignant  tumor  in  one  or  the  other  kidney  when  a 
child  suffers  from  hematuria  the  cause  of  which  is  obscure.  He  further  desires  to  say, 
with  regard  to  surgical  inter\'ention,  that  it  is,  of  course,  essential  that  a  precise 
diagnosis  should  be  made  at  the  earliest  possible  moment.- 

The  tumor  in  cancer  of  the  kidney  presents  a  smooth  or  irregularly 
lobulated  surface,  the  latter  being  especially  frequent  in  young  children. 
In  some  instances  it  contains  blood-vessels  of  sufficient  size  to  impart  a 
sense  of  pulsation  to  the  hand.  The  same  sense  of  pulsation  may  be  ex- 
perienced from  the  impulse  imparted  to  the  tumor  by  the  blood's  coursing 
through  the  aorta. 

In  some  instances  a  feeling  of  semifluctuation  may  be  detected  that 
may  give  rise  to  a  suspicion  of  the  presence  of  fluid;  this  is  especially  true 
of  sarcoma.  The  characteristic  feature  of  the  tumor  is  its  fixedness  of 
position. 

The  pain  dependent  upon  malignant  disease  of  the  kidney  is  not  con- 
stant, the  patient  in  some  cases  being  comparatively  free  from  it.  In  other 
instances  it  is  very  intense  and  resembles  nephralgia  of  a  severe  t}^e.  Ves- 
ical spasm  may  co-exist  as  a  reflex  manifestation  of  the  presence  of  the 
tumor.  Disturbances  of  the  digestive  functions  are  usual  as  a  consequence 
of  the  mechanic  pressure  of  the  tumor  and  the  general  disorder  of  nutri- 
tion it  produces.  Dropsy  of  the  lower  extremities  or  peritoneal  cavity  may 
occur  as  a  consequence  of  venous  obstruction  from  pressure.     In  some  in- 


^  Op.  cit. 

^Alsberg:    Eevue  Mensuelle  des  Maladies  de  I'Enfance,  June,  1888. 


DIAGNOSIS    OF   EEXAL   TUMORS.  895 

stances  peritoneal  inflammation  co-exists  and  enhances  the  dropsical  effu- 
sion. 

Morris's  remarks  on  the  diagnosis  of  renal  tumors  in  general  are  well 
worth  repetition^: — 

Eenal  tumors  are  among  the  most  difficult  of  abdominal  enlargements  to  diag- 
nose correctly.     They  therefore  demand  close  study. 
Ttie  chief  distinctive  points  are  the  following:- — • 

1.  The  large  intestine  is  in  front  of  the  tumor.  Xormally  the  right  kidney, 
unless  enlarged,  lies  a  little  way  from  the  lateral  wall  of  the  abdomen,  behind  and  to 
the  inner  side  of  the  ascending  colon;  not  in  close  contact  with  the  abdominal  wall 
and  outside  the  ascending  colon  as  the  liver  does.  When  the  kidney  is  enlarged  the 
ascending  colon  is  usually  in  front  of  and  toward  the  inner  side  of  the  tumor.  On  the 
left  side  the  descending  colon  is  in  front,  and  inclines  toward  its  outer  side  below; 
in  some  cases  coils  of  small  intestine  may  overlie  either  right  or  left  tumor,  if  the 
enlargement  is  not  sufficient  to  bring  the  kidney  into  direct  contact  with  the  front 
abdominal  wall.  When  the  colon  is  empty,  or  non-resonant,  it  can  be  felt  as  a  roll 
on  the  front  surface  of  the  tumor. 

Bowel  is  never  thus  placed  in  front  of  a  splenic  tumor,  and  but  rarely  in  front 
of  one  of  hepatic  origin.  Rarely — if  ascites  is  present  and  the  liver  is  enlarged  in  an 
irregular  and  misshapen  manner — the  small  intestines  may  float  between  the  liver 
and  abdominal  parietes. 

2.  There  is  no  line  of  resonance  between  the  kidney-dullness  and  the  vertebral 
spines;  and  no  space  between  the  kidney  and  the  spinal  groove  into  which  the 
fingers  can  be  dipped  with  but  little  resistance,  as  there  is  between  the  spleen  and 
the  spine. 

3.  Eenal  tumors  do  not  project  or  protrude  backward  to  any  marked  extent. 
They  fill  up  the  hollow  of  the  loin,  and  may  even  cause  some  actual  fullness  there; 
but  often  there  is  nothing  more  than  the  effacement  of  the  natural  hollow  of  the 
loin.  When  the  tumor  attains  a  large  size,  the  parietes  may  be  projected  laterally 
to  a  degree  sufficient  to  be  observed  at  a  superficial  glance.  Sir  William  Jenner 
says:  "Renal  tumors  never  cause  enlargement  behind.  A  renal  tumor  is  not  visible 
in  the  back,  it  expands  in  front.  A  little  greater  fullness  of  the  loin  there  may  be, 
but  nothing  like  tumor.  Tumors  due  to  disease  of  the  kidney  enlarge  in  front,  while 
abscesses  and  other  lesions  which  may  simulate  renal  tumors  often  cause  considerable 
posterior  projection." 

This  is  an  important  feature  in  relation  to  diagnosis,  and  if  stated  a  little  too 
dogmatically  it  will  serve  the  more  to  impress  a  pretty  general  fact.  There  are  excep- 
tions, however,  as  I  shall  show  farther  on. 

4.  "The  kidney  is  rounded  laterally,  rounded  in  front,  rounded  at  its  inner 
border,  rounded  at  its  upper  border,  rounded  at  its  lower  border.  The  inner  border  is 
usually  lost  against  the  spine,  and  the  upper  border  cannot  be  felt  unless  the  kidney 
is  displaced.  The  kidney  has  no  sharp  edges.  It  is  rounded  on  every  side,  and  in 
disease  never  loses  this  peculiarity"  (Jenner).  AVhen  solid  or  cystic,  and  of  what- 
ever size,  a  kidney-tumor  is  prone  to  retain  some,  often  much,  of  its  natural  outline. 
The  absence  of  any  sharp  edges  marks  off  renal  from  many  hepatic  and  splenic 
enlargements. 

5.  Renal  less  frequently  and  less  markedly  than  hepatic,  splenic,  and  suprarenal- 
capsular  swellings  descend  in  inspiration.  Hepatic  and  splenic,  and  more  especially 
splenic,  enlargements  are  depressed  by  the  contraction  of  the  diaphragm;     whereas 


^  "Surgical  Diseases  of  the  Kidneys. 


S96  SUBGICAX    AFFECTIOXS    OP   THE    EIDXEY. 

kidjaeT-swellings  are  oftea  quite  fixed  in  their  position.  If  the  kidney  and  circum- 
scribed tassnes  liare  been  inflamed,  the  kidney  will  be  bound  down  in  its  natural 
situation  and  there  fixed.  Sir  W.  Jenner  remarks:  ""When  the  kidney  is  enlarged 
by  disease  it  is  rarely  moTable  by  respiration  or  palpation.  When  chronic  changes 
snffid^it  to  exdaxge  tJie  organ  have  occurred,  whatever  their  nature,  adhesions  suffi- 
cient to  ptrevent -moTement  usuaDy  form  between  the  capsule  and  adjacent  parts." 
Withont  doubt  this  is  often  so:  but  in  eases  of  new  growths,  where  the  organ  and 
parts  aixHind  have  not  been  the  seat  of  inflammation,  there  may  be  a  considerable 
dcgi«e  of  morement.  I  hare  seen  a  renal  tumor  desc-end  as  much  as  an  inch  by  a 
deep  in^iration.  and  fall  forward  or  backward  by  its  own  weight,  with  the  more- 
menls  <rf  the  body.  I  therefore  agree  with  Dr.  Dickinson  in  saying:  '""Xo  certain 
infa^sce  is  to  be  drawn  from  the  fact  that  a  tumor  descends  with  inspiration."  and 
I  would  add,  "or  ean  be  moTed  forward  and  backward  by  palpation." 

anight  recognized  this  variation  between  fixity  and  mobility  of  renal  enlarge- 
ments in  etHifcwmity  with  the  variety  of  swelling:  and  he  says,  speaking  of  one  of 
his  eases:  *Oii  pushing  the  anterior  part  of  the  tumor  backward  the  motion  of  the 
tomor  was  felt  by  the  hand  placed  at  the  loin.'" 

6.  When  the  pelvis  of  the  kidney  is  dilated,  the  resulting  tumor  may  press 
ujKin  the  liver  so  as  to  be  indistinguishable  from  it:  it  may.  and  often  does,  reach 
down  into  the  iliac  fossa ;  and  occasionally  it  extends  inward  beyond  the  middle  line 
of  the  abdomen.  I  have  opened  an  hydronephrotic  swelling  which  crossed  the  linea 
alba  fully  two  inches.  As  a  rule,  however,  renal  enlargements  never  invade  the 
pelvis,  rarely  reach  the  median  line,  and  frequently  are  separated  from  the  hepatic 
dullness  by  a  resonant  area. 

7.  Whem  the  tumor  is  large  enough  to  reach  the  front  wall  of  the  abdomen, 
The  naost  anterior  point  at  which  it  comes  into  contact  with  it  is  commonly  about 
:he  level  of  the  umbilicus  or  a  little  higher:  the  lateral  wall  between  the  costal 
TnargJTi  and  the  crest  of  the  ilium  is  then  also  bulged  outward.  In  a  case  recently 
under  nay  care  the  tunaor  presented  a  well-defined  prominence  the  size  of  an  apple 
immediately  below  the  left  costal  margin:  this  prominence  looked  like  a  tumor 
situated  in  and  projecting  from  the  parietes.  with  its  central  point  in  the  linea  semi- 
lunaris and  its  inner  edge  reaching  the  median  line  along  a  distance  of  one  and  a  half 
inches:  it  was,  however,  only  a  part  of  a  large  tumor  weighing  four  pounds,  and 
eompletely  filling  the  left  ilio-cxjstal  space.  By  palpation  it  could  readily  be  moved: 
ajad  it  fell  bodily-  against  the  anterior  abdominal  parietes  when  the  patient  turned 
fnnn  the  reeumbent  po^titm  oa  to  his  right  side:  it  also  moved  freely  with 
r^piration. 

&.  A  symptom  in  this  particular  ease  is  one  which  might  be  expected  to  occur 
in  laige  tumors  of  the  left  kidney,  and  not  in  splenic  enlargements.  There  was  a 
laige  Tarieoeele  of  the  left  side,  which  had  been  gradually  increasing  with  the  growth 
ot  the  tumor,  and  at  the  operation  it  was  seen  to  be  directly  due  to  distortion  and 
distension  of  the  spermatic  vein,  which,  with  the  inferior  mesenteric  vein,  curved 
OTer  the  &ont  and  inner  side  of  the  tumor,  and  was  enlarged  to  the  size  of  the 
ring-fings". 

Thae  are  a  few  exceptional  features  connected  with  renal  tumors  which  must 
be  reanembered: — 

(a}  A  right  renal  tumor  may  push  the  ascending  colon  down,  instead  of  bear- 
ii^  the  gut  forward  in  front  of  itself.  A  tumor  of  either  kidney  may  push  the 
bowel  to  its  inner  side  toward  or  even  beyond  the  median  line,  in  which  case  there 
^  no  reeonanee  in  front  of  the  tumor.  In  the  case  just  mentioned  there  was  some- 
times a  line  of  resonance  over  a  curved  area  of  the  tumor  outside  the  dull  and 
prominent  portion:   and  when  resonance  was  wanting  a  roU  of  bowel  could  be  grasped 


DIAGXOSIS    OF    EEXAL    TUITOES.  '?97 

with  the  finger-tips.  The  tumor  had  grown  forward  on  the  inner  side  of  the  descend- 
ing colon-  so  that  in  the  operation  the  bowel  had  to  be  drawn  inward  qnite  across 
the  front  of  the  mass^  after  dividing  the  outer  layer  of  the  mesocolon. 

In  a  case  at  Middlesex  Hospital  some  years  ago  a  sarcomatous  txtnior  spriD.:^-:.^ 
from  the  cellular  tissue  at  the  hilum  of  the  left  kidney  bulged  forward  below  the 
umbilicus  on  the  left  of  the  median  line,  and  was  entirely  in  front  of  the  boweL  The 
kidney,  probably  as  the  result  of  the  drag  of  the  tumoT,  had  elongated  the  peritoneinn 
into  a  mesentery,  and  had  then  floated  forward  in  front  of  the  descending  colon, 
sigmoid  flexure,  and  small  intestine.  The  tumor,  in  some  respects,  therefore,  re- 
sembled an  ovarian. 

In  connection  with  this  case  I  may  allude  to  one  the  notes  of  wMeh  I  extracted 
from  "Guy^s  Post-mortem  Records.'"  and  which  I  have  previously  mentioned  among 
the  causes  of  acquired  misplacement  of  the  kidney:  the  left  kidney  of  a  woman,  aged 
57,  who  died  of  phthisis,  that  was  displaced  on  to  the  brim  of  the  pelvis  by  a  large 
cyst  in  its  lower  part  which  contained  a  pint  of  fluid-  The  cyst  had  dragged  down 
the  kidney  and  occupied  the  greater  part  of  the  pelvic  cavity. 

A  case  recently  under  treatment  in  the  iliddlesex  Hospital  is  directly  opposite 
to  the  first  case  described  from  that  institution.  A  young  woman  had  a  tmnoT  on 
the  right  side  of  the  abdomen,  first  noticed  after  a  fall  in  which  she  struck  the 
abdomen  over  the  situation  of  the  swelling.  From  the  time  of  the  fall  she  had  had 
pain,  very  scanty  urine,  and  a  high  temperature  and  shivering  fits.  There  was 
resonance  in  front.  Pyonephrosis  of  the  right  kidney  seemed  probable,  and  was 
ultimately  negated  by  the  occasional  resonance  of  the  right  loin.  An  exploratory 
incision  in  the  median  line  of  the  abdomen  revealed,  after  pushing  aside  the  intestines, 
first  one  and  afterward  a  second  ovarian  cyst  of  medium  size:  the  right  was  sup- 
purating, and  pushed  backward  by  the  left  cyst,  which  in  turn  was  eonSned  to  the 
pelvis,  and  hemorrhage  had  taken  place  into  it.  The  cysts  were  removed,  and  the 
patient  made  a  good  recovery.  Even  after  removal  the  right  cyst  was  not  wnlike-  a 
distended  and  sacculated  kidney,  for  the  right  Fallopian  tube,  greatly  thickened  and 
distended  with  pus,  was  adherent  over  the  lower  half  of  one  side  of  it,  and  eont- 
municated  with  it  by  a  large  opening,  thus  giving  the  tube  the  appearanc-e  of  a 
dilated  iireter. 

(6)  Either  a  cystic  or  solid  renal  tumor  may  attain  such  a  size  as  to  occupy 
the  greater  part  of  the  abdomen.  Roberts  quotes  such  a  case  of  encephaloid  left 
kidney  in  a  boy  aged  6:  Spencer  Wells,  an.  encephaloid  in  a  girl  aged  -t  years:  and 
Dickinson,  a  fluctuating  sarcoma  in  a  girl  aged  3  years  which  was  mistaken  for 
ascites,:  and  a  second  in  a  girl  of  the  same  age,  which  roughly  resembled  in  appear- 
ance the  swelling  of  pregnancy.  I  have  rec-orded  a  case  of  cystic  tumor  of  the  left 
kidney  in  a  man  which  nearly  filled  the  abdomen.  In  the  Middlesex  Hospital  Musetnn 
there  is  a  cancerous  tumor  weighing  31  pounds  from  the  left  kidney  of  a  boy  aged 
8  years. 

(c)  There  are  but  few,  if  any,  exceptions  to  the  rule  laid  dowTi  by  Sir  W. 
Jenner,  that  renal  tumors  retain  a  rounded  outline,  and  never  present  a  sharp  edge: 
but  this  does  not  at  all  imply  that  the  normal  outline  of  the  kidney  is  retained  in 
all  cases.  On  the  contrary,  when  the  tumor  involves  only  a  part  of  the  organ,  and  not 
the  whole,  and  therefore  does  not  expand  the  entire  capside  as  it  grows,  it  is  unusual 
for  it  to  have  the  renal  outline. 

(d)  MobUity  of  the  tumor  in  respiration  and  by  palpation  is  so  fer  from  being 
rare  that  it  ought  hardly  to  be  enumerated  among  the  exc-eptional  symptoms.^ 

(e)  A  renal  tumor  may,  as  quite  an  exc-eptional  thing,  c-ause  pointing  on  the 


^  The  authors  experienc-e  agrees  with  ]yir.  Morris's  in  this  regard. 


898  SUEGICAL   AFFECTIOXS    OF    THE    EIDXET. 

posterior  aspect  of  the  body.  iMr.  Holmes  has  reported  a  case  of  pulsating  cancer  of 
the  left  kidney  in  a  man  of  49.  The  disease  'svas  almost  confined  to  the  left  kidney, 
but  presented  a  swelling  over  the  sacrum,  and  caused  edenaa  of  the  back  as  high 
as  the  neck.  The  tumor  weighed  thirty  ounces,  and  had  so  far  destroyed  the  natural 
structure  of  the  kidney  that  not  a  trace  remained. 

When  malignant  growth  or  abscess  afiects  only  part  of  the  kidney,  the  abdomi- 
nal tumor  may  appear  to  be  somewhat  removed  from  the  strict  limits  of  the  renal 
region.  Thus,  when  the  upper  part  of  the  kidney  is  alone  involved  there  is  much 
upward  bulging,  and  the  tumor  may  be  felt  in  the  part  usually  occupied  by  liver  or 
spleen.  In  malignant  disease  of  the  right  kidney  I  have  seen  the  tumor  occupy  a 
great  part  of  the  right  hypochondriac  region,  and  simulate  an  hepatic  tumor. 

if)  Little  or  no  reliance  can  be  placed  in  the  absence  of  changes  in  the  urine. 
Solid  tumors  do  not  always  cause  hematui-ia,  nor  do  accumulations  of  pus  in  the 
kidney  always  cause  a  discharge  of  purulent  urine.  The  tumor  may  not  involve  the 
cavity  of  the  kidney;  or  the  ureter  may  be  temporarily  or  permanently  plugged, 
so  that  the  xu-ine  Avhich  is  passed  may  be  quite  normal.  On  the  other  hand,  however, 
hematuria  and  pyuria  associated  with  the  physical  signs  of  renal  tumor  are  valuable 
adjuncts  in  forming  a  diagnosis.  The  best  way  of  estimating  the  size  of  a  renal 
swelling  is  as  follows:  As  the  patient  lies  on  his  back,  place  the  fingers  of  one  hand 
flat  upon  the  ilio-costal  space,  just  outside  the  erector-spinse  muscles,  and  those  of 
the  other  hand  flat  on  the  front  of  the  abdomen  just  over  the  hand  which  is  behind. 
Then,  during  expiration,  and  while  the  patient's  attention  is  diverted,  a  very  fair 
idea  will  be  obtained  of  the  size  and  weight  of  the  organ  by  depressing  the  fingers  in 
front  as  much  as  possible,  and  tilting  forward  those  of  the  hand  behind.  In  thin 
persons,  and  with  the  aid  of  an  anesthetic,  this  mode  of  examination  is  very  effective. 
By  its  adoption  a  renal  swelling  too  small  to  give  rise  to  dullness  or  percussion  will 
often  be  detected.  Excepting  in  children  and  in  persons  much  emaciated,  a  kidney 
which  is  recognizable  by  the  touch  is  either  movable,  misplaced,  or  diseased.  Sir 
W.  Jenner  points  out  that,  when  the  lower  dorsal  and  lumbar  parts  of  the  spine  are 
curved  well  forward,  the  kidney,  even  though  only  of  natural  size,  may  be  sufficiently 
prominent  to  be  seen  through  the  abdominal  parietes.  He  remarks  that  this  condition 
is  not  uncommon  in  women  and  adds  that  he  once  gave  such  a  case  for  examination 
to  the  candidates  for  the  degree  of  the  University  of  London,  and  was  told  that  the 
tumor  (a  healthy  kidney,  though  probably  somewhat  larger  than  normal)  was  an 
ovarian  tumor  and  should  be  cut  out.  A  spinal  or  a  perinephric  abscess,  or  an 
effusion  of  "blood  or  urine  behind  the  kidney,  will  raise  the  kidney  in  front  of  it 
into  a  prominence  which  can  be  easily  felt,  if  not  actually  seen. 

Feces  in  the  ascending  or  descending  colon  may  be  mistaken  for  the  kidney; 
but  perhaps  a  more  frequent  error  is  to  mistake  an  actual  tumor  for  fecal  accumula- 
tions. 

Having  mentioned  the  usual  and  exceptional  symptoms  of  renal  tumors  as  a 
class,  it  will  be  well  next  to  briefly  state  how  they  differ  from  other  tumors  with 
which  they  are  likely  to  be  confused. 

(a)  From  enlargements  of  the  liver.  Renal  tumors  often  dip  down  or  fade 
off  so  as  to  allow  the  fingers  to  be  depressed  between  the  edge  of  the  costal  cartilages 
and  the  upper  border  of  the  tumor.  Hepatic  tumors  pass  downward  from  beneath 
the  ribs,  and  so  rarely  do  they  have  any  intestine  in  front  of  them  that  the  presence 
of  bowel  in  front  of  a  tumor  may  be  regarded  as  a  strong  indication  that  it  has 
not  its  origin  in  the  liver.  When  the  tumor  is  of  the  right  side,  a  jaundiced  tint  of 
eye,  or  skin,  or  urine,  and  stools  deficient  in  bilious  coloring,  are  suggestive,  to  say 
the  least,  of  its  having  an  hepatic  origin.  A  tumor  developed  in  the  concave  part  of 
the  liver  is  very  likely  to  cause  error  in  diagnosis,  especially  hydatids  in  the  left  lobe 
of  the  organ. 


DIAGNOSIS    OP   EENAL   TUMOES.  899 

(ft)  From  enlargements  of  the  spleen.  The  enlarged  spleen  has  not  bowel  in 
front  of  it;  it  generally  presents  a  sharp  or  well-defined  edge,  beneath  which  the 
fingers  can  be  depressed;  this  edge  is  in  some  cases  notched.  There  is  resonance  be- 
tween the  posterior  edge  of  an  enlarged  spleen  and  the  spinal  column,  and  the  tumor  is 
traceable  upward  beneath  the  ribs.  A  splenic  tumor  is  movable;  a  renal  tumor 
may  be  so,  but  often  it  is  fixed  in  the  loin.  Splenic  tumor  will  not  cause  varicocele; 
a  renal  tumor  may  do  so. 

(c)  Tumors  of  the  suprarenal  capsule  are  not  usually  of  sufficient  size  to  form 
an  abdominal  tumor,  but  when  they  do  it  is  not  easy,  if  it  is  possible,  to  distinguish 
them  from  renal  tumors.  Nor  is  it  clinically  of  importance  to  do  so,  since  new 
groAvths  of  the  suprarenal  capsule,  when  of  any  consequence  from  their  dimensions, 
involve  the  kidney  and  sometimes  completely  efface  it. 

{d)  From  ovarian  tumors.  With  an  ovarian  tumor  the  intestines  lie  behind; 
both  loins  are  resonant;  the  tumor  grows  from  below  upward,  is  generally  more 
central,  and  either  drags  up  the  uterus  or  can  be  felt  as  a  swelling  in  the  pelvis  by 
vaginal  or  rectal  examination.  An  ovarian  tumor  exceptionally  has  intestine  in 
front  of  it:  1.  If  of  small  size  the  bowel  may  not  be  displaced  backward  by  it.  2. 
Adhesions  may  have  formed  between  a  coil  of  intestine  and  the  front  surface  of  the 
tumor,  so  that  the  bowel  retains  an  anterior  position. 

(e)  Enlargement  of  the  lymphatic  glands  in  the  near  neighborhood  of  the  kid- 
ney give  rise  to  a  swelling  very  similar  to  a  renal  tumor.  The  diagnosis  may  some- 
times be>  made  by  the  independent  enlargement  of  one  or  more  lumbar  glands  not 
forming  part  of  the  tumor;  by  the  abruptness  of  the  outline  of  the  swelling;  and 
possibly  even  by  a  protrusion  from  the  growth  along  the  spermatic  cord  into  the 
scrotum. 

(f)  From  flatulent  or  fecal  accumulations  in  the  cecum,  sigmoid  flexure,  or 
colon  renal  tumors  may  be  diagnosed  by  the  absence  of  intestinal  disturbance,  ab- 
dominal pain  and  colic,  and  of  the  distension  by  flatus  which  characterize  over- 
distension of  the  bowel. 

The  proximity  of  the  colon  to  the  kidney  renders  the  diagnosis  between  nephritic 
colic  and  intestinal  colic  sometimes  difficult.  Sir  William  Jenner  wrote:  "Nephritic 
colic  will  cause  loss  of  power  in  the  colon,  and  so  induce  constipation,  thus  favoring 
the  idea  that  the  patient  has  intestinal  colic.  Again,  collections  of  stools  in  the  colon 
may  be  mistaken  for  an  enlarged  kidney;  a  large  enema  will  solve  all  doubt  on  this 
point." 

Before  the  surgeon  commits  himself  to  a  definite  opinion  in  any  doubtful  case 
of  abdominal  tumor,  the  bowels  ought  to  have  been  well  opened  and  the  examination 
of  the  tumor  made  immediately  afterward.  It  will  be  well  to  remember  that  just 
as  there  is  incontinence  of  urine  in  retention,  and  incessant  outpouring  of  fluid 
through  the  mouth  in  gastrorrhea,  so  there  may  be  frequent  discharge  of  small  stools 
from  a  bowel  overloaded  with  feces.  An  opinion  should  be  deferred  in  some  cases  until 
after  a  second  or  third  examination  has  been  made,  and  until  time  has  been  allowed 
for  the  removal  of  fecal  accumulations  if  there  are  any. 

(g)  Fecal  abscess,  perityphlitis,  or  inflammation  of  the  cellular  tissue  about  the 
sigmoid  flexure  will  be  distinguished  by  the  marked  febrile  disturbance,  the  asso- 
ciated intestinal  symptoms,  the  tenderness  over  the  front  surface  of  the  part  affected, 
and  the  lower  position  of  the  swelling,  which  will  be  in  the  iliac  rather  than  in  the 
renal  region  of  the  belly. 

With  reference  to  the  diagnosis  of  cancer  in  particniar,  Morris  says: — 

The  diagnosis  has  to  be  made,  flrst,  as  to  the  seat  of  the  tumor;  second,  as  to 
its  precise  nature. 


900  -v:  -:cAi  ArFBcnoxs  of  the  elbx^t. 

Tfce  e2caie&  iti;»ri.  -       ™-  "  r  wfc««  fiist  aees,  its  direction  of  merease.  and  tlie 

fiae  ctf  sammBda^  -aBanw  «a  peratsaon  will  help  to  Sx.  tbs  mtai 

OK^n  of  the  sweDiEiz  ^^^  oi:^in  in  tiie  fir-car,  ^pleem,  or  avmry.    But 

enars  ■■  Ais  Tsspen-  Toidtahlp.  and  I  ]iaiT<e  found,  on  pcet-mast^ 

esaoHBatian.  a  lai;gie  7  oi  a  man  Mho  kad  beat  supposed  to  be  the 

snbjeett.  of  nnlignaz!-  JNtumilar  errois  as  to  the  ^leen,  -when  the 

idSt  kidne;'  has  hetz.           -  /^^jmser.  are  on  reeord.    The  ra^diiy  of  grovlft  of 

the  ttnnar.  its  sneqiii::  '  ^  '"lalar  ootiiiBe,  and  the  panogressiTdT  eaidieetic 

aspedt  of  the  paticE:  .  i  when  a  swellii^  which  began  <m  one  side 

of  the  ahdoaaai.  a^d  j-.  :-il  ot  a  patioit  either  bdov  the  age  of  five  or 

ovtr  that  a€  sbctr  y-  :-idly  a  wry  lazge  aze,  its  mal^nant  nature  may 

be  diagBosed  with  ii.  -tber  in  duUren  or  adnUs,  it  is  no  meammon 

ihiag  ior  these  taK.-:  .  it  i?f  eight  or  nine  pounds;    soiiw<imeA  thex 

vemA  Airtr  or  Am-.  red  m^entene  glands,  renal  eaneer   i~ 

dL.4ingiuBhed  hnr  its  -^^  liodnlar  ootline;    from  eaneer  oi  the 

tseAam  or  -urtlll  intiK:  i^ristie  intestinal  sjmptoms. 

The  aspirating  :  ^^  j-»nefi.  and  will  show  that  ihi 

fSBor  E  dne  to  en-  .  -  distinct  from  ejFstic  It  can 
do  no  Hton^ 

Tbeatmext. — ^Tlie  uneatnaeDi  <i>i  camcer  ©i  the  kaontj  is  -:.:\;.:T\ii.i:elv 
aliiMiet  aiiogietHier  of  a  poJJiatiTe  chancter.     If  the  disease    -  rTiniiiff: 
iilj.  nc^ureetoiiiT  is  a  le^itimaite  procedure,  and  should  be       .  I' 

i&o  often  negieetcd.  But.  as  a  rule,  bj  the  tune  the  diagnosis  i:  ].  is:*  t^  j 
determined  the  tumor  has  piodnced  seeondaiy  infection  of  the  neirh^crinr 
gjandsu  and.  nec-«s£aiil J.  eomstiiiitional  infection;  hence  opera:    _  -  : 

hope  of  success  even  thougji  it  be  practicable  of  performance.  Here  a  snr- 
gical  operation  vill  only  bring  discredit  upon  oto*  art. 

Ano^mes  and  hemostatie  remedies  are.  of  oomse,  eseni:  :  ::  _       r 

pi\QgrEffi  <rf  the  disease,  our  efforts  being  directed  entirelT  to  Ti,e  proionga- 
lian  of  life  and  the  mplief  of  pain- 
Other  forms  of  tumor  of  the  kidnev.  such  as  large  gummata.  myosar- 
coma, papiEoma,  and  adenoma  occur,  but  thej  are  chiefly  of  pathologic 
interest.    The  aratlaor  has  met  witla  OB^e  ea?*  of  c-hondrosareoma. 

KEXAX.    STFMILIS. 

Benal  syphilis  is  relatively  rare,  er^  --'^-^Kyniently  reeeiTes  compara- 
iirely  little  attention  at  the  hands  of  sr : .  :3aoTitaes-    EJeyes  has  mad  t 

an  ediai^iTe  study  of  the  Kteratmcpe  01  liae  subject,  aiid  laas  shown  by  ids 
qpiotations  from  Taraous  authcr:":' -  "  '  ---^—    -  -••  &  aSeetion."^ 

The  rKuMs  off  Ms  inve^i^-  _      .  _    _       — 

'Lameavmas.  in  34  autopsies  oi  patiewtg  sMeeted  with  viseetal  STfUIiB  imind  On 

kidnev  iaranilwd  in  %.  Hoson  w^as  naore  isrtnnate,  1h»iKw»9  dbai^es  pcet-mortcan  in  14 
«Mt  of  TS  eases.  Tirdtow  believes  that  aanrloid  degenctation  of  the  Mdners  may 
depend  diieetfljr  upon  the  svphHitie  eaehesia.    XL  Wagner  in  9Q00  antjopeies  immi  63 

eases  &i  ^^ysMlSs.  *i€  which  Si  w^ere  aamrimii.  %  oobr  were  srpMloma.  and  the  r^Dainder 


»A  Van  Emen  and  KtyoEs.  p.  3-S3. 


EEXAL   SYPHILIS.  SK!)! 

inflammatory  changes.  Speiss  in  220  sypIuHtie  aniofsks  iorand  7  c&ses  or  gtrafflHaitOiiss 
nephritis,  and  140  damaged  kidneys.  Hot  obviously  syp'MMti&.  Baia&erger  is!  I^ISO 
eases  of  Blight's  disease,  acute  and  ehronie,.  foimd  sypMIis  in  4Q  eases.  Tiyt  sypMIitie 
nature  of  lardac-eous  degeneration  was  first  described  by  Eayer  in  1840.  He  also 
notes  other  forms  of  syphilis  of  the  kidney.  Hans  Hebra  reports  an  excellent  eaae 
of  syphilitic  paraplegia  cttred  by  treatment.  .Abotit  a  momth  after  recovery  the  patienc 
returned  with  swelled  legs  and  intense  albTtnainxEria,  wid^  diaapipeaired.  peempfeSy 
under  large  doses  of  the  iodid  of  potassittm. 

It  is  qnite  diffic-tdt  to  establish  definitely  the  relation  oi  canse  and 
effect  in  eases  of  supposed  syphilitie  disease  of  tke  Mditey.  The  treatiiLeiit 
of  syphilis  per  se  is  frequently  responsible  for  renal  disease.  It  is  not 
impossible  that  large  doses  of  meretny.  long  continued^  may  pToduee 
changes  in  the  renal  stractore:  they  certainly  do  proditce  fanetional  dis- 
turbance, lodin  in  free  doses,  continned.  for  a  long  period-  is  pardcnlarly 
liable  to  produce  irritation  of  the  kidneys.  This  is  readily  imderstood.  if 
the  role  of  the  kidney  in  eliminating  the  iodids  he  taken  into  eonsideration- 

The  claim  that  amyloid  changes  are  due  to  syphilis  jb&j  be  an  errO'T 
in  certain  instances  on  aeconnt  of  the  co-esistence  of  syphilitic  and  ossetaus 
disease.  Diseases  of  the  bones  of  long  standing  oc-cnrring  in  late  syphilis 
are  quite  as  apt  to  produce  lardac-eous  deposits  in  the  kidney  as  are  other 
forms  of  osseous  disease.  In  such  cases  it  would  obTiously  be  difaeult  to 
establish  the  responsibility  of  syphilis  p^r  ge  for  the  renal  complic-ation- 
Again,  the  class  of  cases  of  syphilis  met  with  in  hospital  practice,  where  most 
of  the  observations  hare  heen  made,  is  one  that. is  piec-nliarly  liable  to  lenial 
disease  as  a  consequence  of  exposure  and  intemperate  habits.  The  yielding 
of  renal  symptoms  to  large  doses  of  the  iodid  of  potassium  is  hj  no  means 
eonclusiTe  of  their  dependence  upon  syphilis. 

From  these  considerations  the  author  believes  tliar  quite  a  -  -  -'  -^r 
of  the  cases  quoted  by  Keyes  are  at  least  open  to  question.  It  :-  :  '  —. 
j.owever.  that  cases  of  undoubted  syphilitie  disease  of  the  Mdney  are  met 
^th.  as  might  be  expected  from  the  structure  of  the  organ  and  the  fact 
that  all  the  other  viscera  are  susceptible  to  syphilitie  changes.  The  kf dn  ey 
is  certainly  often  affected  in  early  svpMlis,  although  the  precise  ehazaeter  of 
the  changes  in  the  organ  is  suh  judiee. 

MoKBiD  AxATOiTT. — The  various  syphilitie  changes  present  in  the  kid- 
ney in  different  cases  are  ( 1 )  vaso-dilation  or  hyperemia  [probable^ : 
lymphatic  obstruction  and  hyperplasia  [probable]:    {o)  dilfose  intersLiLial 
infiltration;    (4)  contraction  from  c-onnective-tissue  formation:    (-5'i  guirmiy 
nodules:   (6)  arterioselerosis  [Greenfield-Wagner]. 

The  diffuse  form  of  deposit  is  apt  to  be  limited  to  c-ertain  portions  of 
the  kidney.  Cirrhosis  of  the  organ  may  oc-cur  iin  certain  ciretmiscEibed 
areas,  the  rest  of  the  kidney  remaining  healthy.  The  sor&ee  of  such  a 
kidney  upon  examination  post-mortem  presents  a  generally  thickened  and 
firmly  attached  capsule  with  indentations  at  the  site  of  the  cirrhosis-    The 


902  SHEG1CAL    AFFECTIONS    OF    THE    KIDNEY. 

cirrhotic  spots  are  loimd  to  be  hardened  and  very  dense  upon  section.  The 
circumscribed  sj^philoma  found  in  the  kidney  is  similar  to  that  found  in 
other  viscera,  and  occurs  in  the  form  of  yellowish  nodules.  Histologically 
it  is  identic  with  syphiloma  elsewhere. 

Symptoms'  of  Eenal  Syphilis. — There  are  no  special  symptoms  char- 
acterizing syphilitic  kidney;  hence  cases  in  which  it  is  possible  to  diagnose 
this  form  of  renal  disease  are  rare,  although  a  probable  diagnosis  is  occa- 
sionally warrantable. 

Syphilitic  Nepheitis  (So  Called). — Keyes,  Lancereaux,  and  Hardy 
have  called  attention  to  the  fact  that  the  early  stages  of  syphilis  are  occa- 
sionally attended  by  albuminuria.  These  authors  have  respectively  attrib- 
uted the  albuminuria  (1)  to  the  prolonged  administration  of  mercury,  (2) 
the  debilitating  effects  of  the  syphilitic  virus,  and  (3)  to  large  doses  of  the 
iodid  of  potassium. 

The  author  has  noted  in  a  number  of  cases  albuminuria  coincidently 
with  the  early  secondary  eruptions,  usually  during  the  roseola  and  papular 
exanthem.  The  albuminuria  in  these  cases  is,  in  the  author's  opinion,  at- 
trilnitable  to:  1.  Vasomotor  changes  in  the  circulation  of  the  kidney  de- 
pendent upon  the  same  central  nervous  influences  as  the  roseola.  The  roseola, 
as  already  asserted,  is  probably  produced,  not  by  the  deposition  of  syphilitic 
material  in  the  tissues,  but  by  vasomotor  dilation  of  the  capillaries  of  the 
skin  as  a  consequence  of  the  impression  of  syphilitic  toxins  upon  the  cen- 
tral nervous  system.  This  same  disturbing  influence  is  perfectly  capable  of 
inducing  transitory  hyperemia  of  the  kidney  with  consequent  albuminuria. 
2.  The  local  irritation  produced  by  syphilitic  toxins  as  they  fllter  through 
the  kidney.  3.  Engorgement  and  hyperplasia  of  the  renal  lymphatics. 
4.  Infiltration  of  the  vascular  walls. 

Teeatment. — The  treatment  of  renal  syphilis  is  that  of  the  general 
disease,  with  the  same  regard  for  the  stage  ■  of  the  affection  in  which  the 
renal  complication  develops. 

opeeations  upon  the  kidney. 

The  various  operations  involving  surgical  kidney  are  (1)  nephrotomy 
[simple  incision  and  drainage  of  the  kidney];  (.2)  nephrolithotomy;  (3) 
curetting  of  the  kidney;    (4)  nephrorraphy;    (5)  nephrectomy. 

Nepheotomy. — Simple  incision  of  the  kidney  is  indicated  in  cases  of 
hydronephrosis  or  pyonephrosis,  or  for  the  purpose  of  exploration.  Should 
stone  exist,  the  operation  is  to  be  extended  and  nephrolithotomy  performed. 
Incision  with  subsequent  prolonged  drainage  are  often  all  that  is  required  in 
purulent  deposits  in  and  about  the  kidney.  It  is  always  indicated  as  a  pre- 
liminary operation,  for  it  certainly  would  be  unwise  to  perform  nephrectomy 
unless  the  course  of  the  case  proves  the  latter  operation  to  be  absolutely 
necessary,  for  there  is  great  danger  of  serious  disease  in  the  Qpposite  kid- 
ney, providing  one  exists.     Cases  have  been  recorded  in  which,  after  re- 


OPERATIONS    UPON    THE    KIDNEY.  903 

moval  of  a  pathologic  kidney,  the  unfortunate  discovery  has  been  made 
that  the  extirpated  organ  was  the  only  one  possessed  by  the  individual.  At 
a  meeting  of  one  of  the  London  medical  societies  there  were  shown  two 
kidneys  from  different  subjects,  one  of  which,  had  been  removed  on  autopsy 
from  a  woman  on  whom  ovariotomy  had  been  performed,  and  which  proved 
to  be  her  only  kidney,  no  trace  of  the  other  organ  being  discoverable.  The 
second  specimen  shown  had  been  removed  on  account  of  renal  disease.  The 
two  specimens  were  an  apt  illustration  of  the  occasional  danger  of  ne- 
phrectomy due  to  congenital  anomalies  of  the  kidney.  The  patient  from 
whom  the  kidney  had  been  removed  by  nephrectomy,  recovered  and  left 
the  hospital  in  about  a  month.  If,  however,  such  an  anomaly  had  been 
present  in  him  as  existed  in  the  woman  from  whom  the  first  specimen  was 
removed,  death  would  have  been  inevitable.  Cases  have  been  reported  in 
which  this  mistake  was  made.  It  was  formerly  a  very  difficult  matter  to 
recognize  the  absence  of  one  kidney  prior  to  operative  procedures.  With 
the  cystoscope  it  is  now  a  much  simpler  matter,  but  even  with  that  instru- 
ment it  is  not  always  practicable.  So  great  is  the  difficulty  sometimes,  that 
it  has  been  recommended  that  the  operation  be  performed  through  a  median 
incision  in  the  abdomen,  which  will  enable  the  operator  to  determine  the 
presence  and  pathologic  condition  of  both  organs.  According  to  Fenwick, 
it  is  always  easy  to  watch  the  flow  of  urine  through  the  ureters  into 
the  vesical  cavity  via  the  cystoscope,  thus  affording  positive  proof  of  the 
existence  of  duplicate  secreting  organs.  As  already  stated,  the  cystoscope  is 
sometimes  of  great  value;  the  facility  with  which  it  can  be  used  depends, 
however,  largely  on  the  condition  of  the  bladder.  In  many  cases  the  de- 
termination of  the  existence  of  the  normal  number  of  kidneys  is  an  easy 
matter,  especially  in  the  female,  it  being  possible  in  the  latter  to  catheterize 
each  ureter.  Harris's  method  is  very  useful.  A  careful  study  of  the  case 
may  shed  some  light  upon  the  probable  existence  of  the  normal  number  of 
kidneys  in  instances  where  cystoscopy  fails  or  is  impracticable.  For  ex- 
ample, if  a  patient  with  profound  pathologic  changes  in  one  kidney  has 
little  or  no  general  symptoms  of  uremic  poisoning,  and  the  daily  excretion 
of  urea  approximates  the  normal,  it  may  reasonably  be  inferred  that  suffi- 
cient compensatory  excretion  is  being  carried  on  by  the  other  organ. 

The  incision  in  nephrotomy  is  the  same  as  in  nephrolithotomy. 

Nepheolithotomy.— ISTephrolithotomy  has  become  a  recognized  and 
popular  operation.  The  first  collective  investigation  of  cases  and  results 
of  the  operation  was  published  by  Morris,  who  himself  first  performed 
the  operation  in  1880.^  In  his  account  of  the  operation  it  is  stated  that, 
prior  to  the  publication  of  his  work,  the  operation  had  been  performed  21 
times,  with  19  successful  results.  One  of  the  fatal  cases  was  due  to  sup- 
pression of  urine  and  uremia  incidental  to  profound  disease  in  the  remain- 


'Surgical  Diseases  of  the  Kidney." 


904  STJEGICAL   AFFECTION'S    OF    THE    KIDNET. 

mg  kidney,  and  the  other  to  a  toxic  dose  of  morphia.  The  operation  is 
nowadays  quite  common. 

Op&ration.  —  The  operation  is  as  follows:  An  incision  from  4  to  5 
inches  in  length  is  made  ^/^  of  an  inch  below,  and  parallel  with,  the  twelfth 
rib.  This  incision  is  carried  down,  layer  by  layer,  until  the  outer  edge  of 
the  quadratus-lumborum  muscle  is  exposed;  this  may  be  drawn  aside,  or, 
if  necessary,  cut  through.  Bleeding  should  be  thoroughly  checked  before 
the  abdomen  is  entered.  After  the  cushion  of  fat  about  the  kidney  is  ex- 
posed, no  further  cutting  should  be  done,  as  a  rule,  until  the  kidney  is 
reached,  the  connective  tissue  and  fat  being  torn  through  by  forceps  and 
the  fingers.  When  the  kidney  is  exposed  the  index  finger  readily  explores 
its  entire  surface  and  pelvis,  detecting  with  great  facility  any  roughness, 
swelling,  or  induration  at  any  point  corresponding  to  the  location  of  a 
stone.  It  is  necessary  to  employ  counter-pressure  by  means  of  the  opposite 
hand  upon  the  abdomen,  else  the  kidney  may  be  easily  dislocated  into  the 
abdominal  cavity.  If  necessary,  the  kidney  may  be  palpated  by  the  thumb 
and  finger  in  the  wound.  If  no  stone  is  found  in  this  manner,  an  exploring 
needle  should  be  used  and  the  renal  tissue  punctured  here  and  there  until 
the  stone  is  found  or  proved  to  be  either  absent  or  inaccessible  to  the 
needle.  If  stone  is  detected,  it  should  be  cut  down  upon  and  removed. 
Should  the  attempt  to  find  the  stone  with  the  needle  be  unsuccessful,  an 
incision  should  be  made  through  the  substance  of  the  kidney  into  the  pelvis 
of  the  organ.  A  small  stone  that  escapes  the  needle  may  perhaps  thus  be 
found.  The  wound  should  be  dressed  by  inserting  a  drainage-tube  and 
suturing  about  it,  the  whole  being  covered  with  antiseptic  dressings.  The 
urine  will  escape  through  the  wound  for  a  time,  rarely  longer  than  a  couple 
of  weeks.  Small  stones  that  have  escaped  detection  even  by  the  finger  have 
been  known  to  come  away  subsequently  in  the  wound  discharges. 

CuEETTiNG  THE  KiDNEY. — This  is  a  new  departure.  Danforth  has 
advocated  a  procedure  which  he  has  long  practiced  for  the  purpose  of  avoid- 
ing free  incision,  or  complete  extirpation,  in  pyonephrotic  and  calculous 
kidney.    One  of  the  cases  reported  is  of  considerable  interest. 

Case. — Suppurative  pyelitis.  The  kidney  was  exposed,  and,  in  lieu  of  incision, 
was  punctured  with  a  grooved  director.  The  opening  thus  made  was  enlarged  by 
means  of  a  pair  of  hemostatic  forceps  in  order  to  avoid  hemorrhage.  Through  this 
opening  the  cavity  of  the  kidney-pelvis  Avas  irrigated  with  a  warm  antiseptic  solu- 
tion until  it  returned  perfectly  clear.  A  curette  was  then  introduced  into  the 
opening  and  the  trabeculse  of  the  kidney  produced  by  the  disease  broken  down  so 
far  as  possible  into  one  cavity.  The  kidney  was  again  washed,  then  with  a  curette 
its  interior  was  thoroughly  scraped,  this  procedure  bringing  away  large  shreds  of 
coagulated  lymph  (the  so-called  pyogenic  membrane),  granular  and  sabulous  debris. 
This  was  all  washed  away  until  the  antiseptic  solution  returned  perfectly  clear. 
Thorough  drainage  was  instituted,  antiseptic  dressings  applied,  and  the  case  left 
to  Xature.  Recovery  was  speedy,  all  the  symptoms  being  relieved  and  the  wound 
healing  kindly.  This  case  demonstrates  conclusively  the  feasibility  of  curettage  as 
a  substitute  for  the  more  serious   operations  of  nephrotomy   and  nephrectomy.     Tt 


OPEEATIOXS    UPON    THE    KIDXEY.  905 

shows  also  that  the  renal  tissue  will  tolerate  an  amount  of  mechanic  interference 
that  is  at  first  thought  surprising.  It  further  demonstrates  that  the  same  principles 
of  surgery  that  are  applicable  to  abscesses  in  other  situations  may  with  propriety  be 
adopted  in  cases  of  suppurative  disease  of  the  kidney  or  its  pelvis. 

The  operation  of  enrettement  is  certainly  worth  consideration  where 
simple  incision  and  drainage  have  been  decided  upon  with  the  desire  to 
save  the  damaged  kidney  or  bring  about  a  cure  in  cases  in  which  ne- 
jDhrectomy  seems  undesirable  or  dangerous. 

•  ISTepheectomy. — JSTephrectomy,  or  complete  extirpation  of  the  kidney, 
was  first  performed  by  Simon,  of  Heidelberg,  in  1869.  This  operation  be- 
comes necessary  when  the  preceding  ones  have  failed.  It  is  rarely  indicated 
as  a  primary  operation,  excepting  in  cases  of  tumor  of  a  malignant  char- 
acter, or  other  disease  in  which  incision  and  drainage  or  curetting  offer  no 
hope  of  success.  The  operation  consists  in  the  complete  removal  of  the 
kidney,  and  is  performed  in  two  ways.  In  the  most  popular  method  of 
operation  the  incision  is  made  in  the  lumbar  region,  and  the  peritoneal 
cavity  is  not  interfered  with.  The  position  of  the  wound  in  this  operation 
is  very  favorable  to  drainage. 

ISTephrectomy  is  indicated  (1)  in  malignant  tumors;  (2)  in  rupture  and 
other  traumatic  accidents  to  the  kidney  or  ureter  in  which  the  destruction 
of  the  renal  tissue  is  extensive  or  the  ureter  completely  torn  across;  (3) 
for  wandering  kidney  when  operations  for  fixation  of  the  organ  are  im- 
practicable or  ineffectual;  (4)  for  incurable  fistulas  following  incision  and 
drainage  and  due  to  extensive  disorganization  of  the  organ;  (5)  for  un- 
deniable tubercular  disease  supposed  to  be  limited  to  one  kidney;  (6)  for 
renal  calculus  in  cases  in  which  the  kidney  is  extensively  disorganized  or 
the  stone  is  so  large  that  it  is  impracticable  to  remove  it  without  extensive 
destruction  of  the  organ. 

The  lumbar  operation  is  usually  to  be  selected,  excepting  in  cases  in 
which  the  kidney  is  displaced  into  the  pelvic  cavity  and  in  large  tumors, 
such  as  sarcoma  and  encephaloid. 

Operation. — In  performing  the  posterior  or  lumbar  operation  a  trans- 
verse incision  4  ^/o  inches  in  length  is  made,  parallel  with  the  last  rib,  about 
^/^  of  an  inch  beloAv  its  lower  border;  a  second  incision,  extending  down- 
ward toward  the  crista  ilii  and  intersecting  the  first  incision  about  an  inch 
from  its  posterior  angle,  may  be  made  if  necessary.  The  kidney  is  exposed 
as  in  nephrolithotomy,  and  detached  from  the  surrounding  tissues  by  the 
finger.  It  is  next  drawn  from  the  wound  and  the  ureter  and  renal  vessels 
separately  ligated  as  low  as  possible.  It  may  be  necessary  to  place  this  liga- 
ture in  position  before  drawing  the  kidney  out  of  the  wound,  this  being  per- 
haps the  easiest  procedure.  A  second  ligature  is  passed  aroimd  the  pedicle 
just  below  the  kidney;  the  portion  of  the  pedicle  between  the  two  is  then 
cut  across  with  scissors.  After  hemorrhage  has  been  checked,  the  ligature 
should  be  cut  short,  the  pedicle  sprinkled  with  iodoform  and  dropped  back 


906  SUEGICAL   AFFECTIONS    OF    THE    KIDNEY. 

into  the  woimd.  Gauze  drainage  should  be  introduced  and  the  wound 
sutured,  after  which  the  ordinary  dressing  of  sterilized  or  horated  cotton 
and  iodoform  gauze  should  be  applied.  The  subsequent  management  of 
the  case  is  the  same  as  that  of  any  deep  wound  that  is  allowed  to  heal  by 
granulation. 

In  the  anterior  or  abdominal  operation  an  incision  may  be  made  in  the 
median  line,  or  along  the  external  edge  of  the  rectus  abdominis  muscle  on 
the  side  corresponding  to  the  affected  kidney.  The  latter  is  the  most  gen- 
erally accepted  method.  The  separate  steps  of  the  operation  are  precisely 
the  same  as  in  laparotomy  for  other  conditions.  The  kidney  is  to  be  freed 
and  removed  like  any  abdominal  tumor.  A  drainage-tube  may  or  may  not 
be  required,  this  being  composed  of  vulcanized  rubber  or  glass,  as  for  an 
ordinary  ovariotomy.  Antiseptic  dressings  are  applied  as  usual.  When  a 
drainage-tube  is  introduced  into  the  abdomen  in  this  manner  it  necessitates 
frequent  cleansing  by  means  of  suction  with  a  syringe.  If  the  process  for 
which  the  kidney  is  removed  be  of  a  suppurative  character,  it  is  best  to 
close  the  abdominal  wound  entirely,  making  an  incision  in  the  lumbar  re- 
gion for  drainage.  Drainage  in  this  situation  is  far  preferable  to  abdominal 
drainage  in  such  cases.  The  anterior  operation  should  never  be  performed 
where  possible  to  avoid  it. 

Nephrgrraphy. — Fixation  of  the  kidney  was  first  performed  by  Hahn, 
of  Berlin.  It  is  unnecessary  to  describe  the  successive  steps  of  the  opera- 
tion of  nephrorraphy,  as  the  method  of  exposure  of  the  kidney  is  precisely 
the  same  as  that  just  described,  the  only  difference  being  that,  in  lieu  of 
removal  of  the  organ,  it  is  stitched  to  the  edges  of  the  wound  by  four  to 
six  medium-sized  silk  or  chromicized-gut  sutures.  It  is  well  to  include  the 
periosteum  of  the  last  rib  in  the  sutures  where  possible.  Temporary  gauze 
packing  and  secondary  suture  are  advisable,  as  giving  more  and  firmer  ad- 
hesions. Adhesion  and  fixation  of  the  kidney  are  favored  by  scratching  the 
surface  of  the  organ  freely  with  a  large  needle  or  dissecting  up  its  capsule 
a  little. 


CHAPTER  XXXVIII. 

Diseases  of  the  Ureter. 

The  surgery  of  the  ureter  may  be  said  to  be  still  in  its  infancy,  as 
systematic  operations  for  its  diseases  and  injuries  are  of  very  recent  date. 
Our  knowledge  of  ureteral  pathology  is  still  very  meager.  The  conditions 
of  the  ureter  demanding  attention  are:  1.  Congenital  deformities  with 
resuilting  obstruction.  2.  Mechanic  obstruction  due  to  (a)  the  pressure  of 
tumors;  (b)  inflammatory  pressure  or  adhesions;  (c)  stricture  from  inflam- 
mation, infectious  or  traumatic;    (d)  impacted  calculus. 

Congenital  deformities  of  the  ureter  exceptionally  call  for  surgical  in- 
tervention aimed  directly  at  the  tube  itself,  for  the  reason  that  the  results 
of  such  congenital  deformities  as  twisting,  kinking,  atresia,  or  valvular  ob- 
struction of  the  ureter  are  such  as  to  demand  attention  directed  to  the 
kidney  per  se. 

Ureteritis  and  periureteritis  sometimes  result  from  an  extension  of 
gonorrheal  or  other  infection  upward  from  the  bladder. 

Diagnosis  is  difficult;  but  should  the  diagnosis  be  established  by  the 
discovery  of  thickening  and  tenderness  limited  to  the  course  of  the  ureter, 
an  operation  for  freeing  the  ureter  from  the  pressure  of  the  inflammatory 
material  about  it  might  become  necessary.  Should  the  inflammation  re- 
sult in  stricture  of  the  ureter,  as  evidenced  by  hydronephrosis,  catheteriza- 
tion of  the  ureter  from  the  bladder  with  the  assistance  of  the  cystoscope, 
or  by  the  Kelly  method  of  direct  illumination  via  the  endoscopic  tube,  may 
be  practiced. 

Obstruction,  whether  from  inflammation  or  the  passage  of  calculi,  is 
most  likely  to  occur  at  the  normal  points  of  narrowing  of  the  ureter.  These 
are  located  (1)  about  an  inch  and  a  half  from  the  uretero-pelvic  opening, 
(2)  at  a  point  corresponding  with  the  passage  of  the  ureter  over  the  iliac 
artery,  and  (3)  at  the  point  where  the  ureter  penetrates  obliquely  the  mus- 
cular vesical  wall.  The  most  frequent  cause  of  inflammation  and  obstruc- 
tion of  the  ureter  is  traumatic  injury  from  the  passage  or  lodgment  of 
calculi  of  nephritic  origin.  It  is  also  occasionally  injured  by  penetrating 
wounds  of  the  abdomen  and  pelvis,  or  sharp  spicules  of  bone  incident 
to  fracture  of  the  pelvis.  Complete  perforation  of  the  ureter  may  occur 
from  the  impaction  of  a  calculus  within  its  lumen.  This  may  produce 
an  immediate  solution  of  continuity,  or  the  perforation  may  not  occur 
until  after  the  lapse  of  some  little  time,  through  the  medium  of  ulcera- 
tion. The  immediate  result  of  perforation  of  the  ureter  is  necessarily 
a  collection  of  urine  in  the  flank,  presenting  a  lumbar  tumor  after  a  suffi- 
cient size  has  been  attained.     Should  the  wound  involve  the  peritoneum, 

(907) 


908  DISEASES    OF    THE    UEETEE. 

which  lies  anteriorly  to  the  ureter,  fatal  peritonitis  speedily  ensues.  Wounds 
often  amounting  to  complete  division  of  the  ureter  are  by  no  means  unu- 
sual in  the  removal  of  pelvic  tumors.  The  ureter  may  be  torn  or  cut  across. 
This  accident  has  most  often  occurred  in  removing  large  uterine  myomata. 

Since  the  operation  of  vaginal  hysterectomy  for  utero-pelvic  disease 
has  become  popular,  injury  or  division  of  the  ureter  has  occurred  quite  fre- 
quently. As  may  readily  be  seen,  the  danger  of  injury  of  the  ureter  is 
greatest  when  it  is  imbedded  in  inflammatory  deposits  and  surrounded  by 
old  adhesions.  An  accident  to  the  ureter  is,  however,  not  likely  to  occur 
if  the  operator  be  cautious  and  experienced,  as  is  well  shown  by  the  record 
of  Eichelot,  who,  in  three  hundred  vaginal  hysterectomies,  experienced  the 
accident  but  once.  It  should  be  remembered  in  performing  pelvic  opera- 
tions that  the  ureter  is  firmly  adherent  to  the  peritoneum,  which  invests  it 
anteriorly.  In  pulling  the  peritoneum  about,  therefore,  the  ureter,  being 
practically  unattached  behind,  simply  lying  in  a  bed  of  cellular  tissue,, 
moves  with  the  membrane. 

Injury  of  the  ureter  may  demand  the  formation  of  a  urinary  fistula 
in  the  flank,  or  lumbar  region,  with  a  view  to  removal  of  the  kidney  if 
means  to  reunite  the  divided  ends  of  the  ureter  fail  later  on.  Where  a 
diagnosis  of  division  of  the  ureter  is  made,  it  should  be  cut  down  upon, 
providing  this  has  not  already  been  done  as  in  abdominal  pelvic  operations, 
and  sutured. 

An  impacted  calculus  in  the  ureter  is  attended  by  renal  colic.  When 
the  symptoms  are  not  relieved,  and  the  pain  and  tenderness  tend  to  localize 
at  some  point  in  the  course  of  the  ureter,  an  impaction  of  the  calculus  in 
that  structure  is  probable.  The  diagnosis  is  rendered  still  more  certain 
should  an  hydronephrotic  tumor  appear  in  the  flank.  The  marked  diminu- 
tion in  the  quantity  of  the  urine  incident  to  the  obstruction  of  the  flow 
from  the  kidney  of  the  affected  side  is  an  important  point  in  the  diag- 
nosis. An  impacted  calculus  in  the  lower  portion  of  the  ureter  may  some- 
times be  detected  by  digital  exploration  of  the  rectum  or  vagina  or  both. 
In  thin  subjects  the  stone,  if  located  higher  up  in  the  ureter,  may  possibly 
be  detected  by  palpation  through  the  abdominal  walls,  but  a  lumbar  or 
abdominal  incision  is  usually  necessary  to  a  correct  diagnosis.  When  found, 
the  ureter  should  be  opened  longitudinally  and  the  calculus  removed.  The 
resulting  longitudinal  wound,  and  all  wounds  of  a  similar  character,  require 
suturing,  followed  by  thorough  drainage.  The  posterior  or  extraperitoneal 
method  of  reaching  the  ureter  is  always  to  be  preferred.  Stricture  of  the 
ureter  with  considerable  cicatricial  stenosis  has  been  dealt  with  by  Tenger 
in  the  following  manner: — - 

A  longitudinal  incision  is  made  through  the  strictured  portion.  The  ureter  is 
then  bent  in  such  a  manner  that  the  upper  and  lower  angles  of  the  wound  can  be 
sutured  together;  the  edges  of  the  wound  between  the  two  approximated  angles  and 
the  angle  formed  by  the  flexion  of  the  ureter  are  then  united  with  sutures. 


OPEEATIOKS  OX  THE  UKETEK.  909 

The  ureter  may  be  exposed  to  the  best  advantage  by  an  incision  from 
the  twelfth  rib  to  the  crista  ilii,  Just  anterior  to  tlie  erector-spinse  muscle, 
about  three  and  one-half  inches  from  the  spinous  processes  of  the  lumbar 
vertebra.  This  incision  can  be  carried  forward  and  downward,  above  and 
below,  along  the  rib  and  parallel  with  Poupart's  ligament  to  a  sufficient 
distance  to  secure  the  formation  of  a  good-sized  flap.  Upon  raising  this 
flap  a  very  extensive  surface  of  the  parietal  peritoneum  is  exposed.  Careful 
exploration  with  the  finger  separating  the  peritoneum  from  the  retroperi- 
toneal tissues  backward  to  the  spinal  column  will  disclose  the  ureter  lying 
somewhat  less  than  an  inch  from  the  point  of  adhesion  of  the  peritoneum 
to  the  spine. 

Where  the  ureter  is  completely  divided  transversely,  attempts  at  direct 
suture  and  reunion  have  failed,  because  of  the  great  depth  of  the  field  of 
operation  and  the  difficulty  encountered  in  so  suturing  the  divided  ends 
that  without  occlusion  of  the  lumen  of  the  ureter  retraction  of  the  cut  ends, 
and  consequently  failure,  will  not  occur.  The  procedure  that  has  usually 
been  adopted  has  been  to  ligate  the  distal  cut  extremity  and  implant  the 
proximal  extremity  into  the  skin  as  far  posteriorly  as  possible,  thus  secur- 
ing a  permanent  urinary  fistula.  Under  such  circumstances,  if  the  opposite 
kidney  is  sound,  or  sufficiently  so  to  warrant  operative  interference  with 
the  organ  upon  the  wounded  side,  removal  of  the  latter  may  be  practiced 
later  on.  It  is  the  author's  impression  that  where  this  is  done  it  is  wise  to 
completely  occlude  the  fistula  for  a  short  time,  thus  interfering  with  the 
function  and  nutrition  of  the  affected  kidney,  and  necessitating  the  begin- 
ning of  compensatory  action  of  the  opposite  kidney  before  such  action  is 
necessitated  by  the  entire  removal  of  its  fellow.  The  idea  has  also  sug- 
gested itself  that  direct  primary  suture  of  the  cut  ends  of  the  ureter  might 
be  successfully  practiced  by  passing  an  extremely  fine  elastic  catheter  into 
the  ureter  in  such  manner  as  to  couple  the  cut  extremities,  and  enable  the 
operator  to  stitch  the  wounded  edges  together  accurately  and  firmly  about 
the  catheter.  The  catheter  should  be  long  enough  to  penetrate  into  the 
cavity  of  the  bladder.  This  might  be  inserted  by  the  Kelly  method,  or  a 
suprapubic  section  might  be  made,  through  which  the  catheter,  or  a  liga- 
ture attached  to  its  extremity,  could  be  withdrawn  from  the  cavity  of  the 
bladder,  thus  facilitating  the  withdrawal  of  the  catheter  from  the  ureter 
at  the  end  of  four  or  five  days,  at  which  time  the  union  between  the 
divided  ends  of  the  ureter  will  probably  have  become  sufficiently  firm  to 
guarantee  permanent  re-establishment  of  continuity. 

When  the  division  of  the  ureter  is  in  a  favorable  position,  it  may  be 
practicable  to  implant  the  ureter  into  the  fundus  of  the  bladder.  Implanta- 
tion into  the  sigmoid  or  rectum  is  sometimes  necessitated  by  the  complete 
extirpation  of  the  bladder  for  malignant  disease.  Under  such  circumstances 
uretero-rectal  implantation  is  justifiable.  It  is  very  rarely  so  rmder  any  other 
circumstances. 


910 


DISEASES    OF    THE    UKETEE. 


I 


Van  Hook's  operation  for  reuniting  the  cut  extremities  of  the  ureter 
by  invagination  of  tlie  proximal  into  the  distal  portion  has  been  successfully 
practiced.     The  operation  is  performed  as  follows: — 

The  lower  portion  of  the  ureter  should  be  ligated  from  one-eighth  to  one-fourth 
of  an  inch  below  the  cut  extremity.  About  one- fourth  of  an  inch  below  the  ligature 
a  longitudinal  incision,  twice  as  long  as  the  diameter  of  the  ureter,  is  made.  An  in- 
cision is  made  in  the  upper  segment  of  the  ureter  with  scissors,  extending  upward  and 
opening  the  canal  for  a  distance  of  one-fourth  of  an  inch.  Two  small  cambric  needles, 
threaded  with  a  single  strand  of  fine  catgut,  are  now  passed  through  the  wall  of  the 
upper  end  of  the  ureter,  one-eighth  of  an  inch  from  the  cut  extremity.  The  needles 
should  be  from  one-sixteenth  to  one-eighth  of  an  inch  apart,  traversing  the  ureter  from 
wdthin  outward.     The  needles  are  next  carried  through  the  longitudinal  slit  in  the 


I 


No.  1.  No.  2.  ___ 

Fig.  205.^ Van  Hook's  method  of  anastomosis  of  the  divided 


distal  end  of  the  ureter  into  the  tube,  and  made  to  traverse  its  lumen  for  a  distance  of 
one-half  inch,  at  which  point  they  a^e  made  to  penetrate  the  wall  of  the  duct  a  short 
distance  apart!  By  traction  upon  the  loop  of  catgut  thus  formed,  the  proximal  portion 
of  the  ureter  is  drawn  into  the  lower  one,  thus  splicing  the  two  extremities  securely 
together.  The  catgut-ends  are  then  securely  tied  together.  The  operation  is  com- 
pleted by  enveloping  the  ureter  with  peritoneum  and  stitching  the  latter  over  and  to 
the  tube  with  fine  silk  sutures  that  are  made  to  traverse  the  muscular  layer  of  the 
ureter  only. 

Coe  has  operated  successfully  upon  the  lower  third  of  the  ureter  in  the 
female  through  the  vaginal  vault. 

Where  it  is  determined  to  transplant  the  ureter  into  the  bladder,  it 
may  be  done  as  follows: — 


OPEKATIOXS  ON  THE  UEETEE.  911 

A  wound  is  made  in  the  vesical  walls  separating  the  visceral  peritoneum 
for  a  distance  of  perhaps  an  inch.  The  vesical  walls  are  then  penetrated, 
and  the  cavity  of  the  bladder  entered  obliqnely.  The  tube  is  then  stitched 
into  the  wall  of  the  viscus  so  as  to  include  the  wall  of  the  ureter,  the  peri- 
toneum, and  the  muscular  wall  of  the  bladder. 

This  method  of  fixation  is  more  rational  than  stitching  the  ureter  into 
an  opening  that  immediately  traverses  the  vesical  walls. 

Where  the  upper  end  of  the  ureter  is  sufficiently  long,  the  track  of 
the  wound  into  which  the  tube  is  to  be  transplanted  may  be  made  longer. 
Especial  care  should  be  taken  to  avoid  entering  the  bladder  at  an  abrupt 
angle,  as  by  so  doing  danger  is  incurred  of  kinking  of  the  vesical  extremity 
of  the  ureter  as  the  wound  in  the  bladder  cicatrizes. 

Kraske's  method  of  sacral  resection  facilitates  access  to  the  lower  ex- 
tremity of  the  ureter,  and  may  possibly  be  of  service  in  wounds  low  down 
in  the  pelvis. 

ExPLOEATioisr  OF  THE  Ueetee. — Direct  exploration  of  the  ureter  is 
one  of  the  most  remarkable  achievements  that  have  thus  far  been  made  in 
genito-urinary  surgery.  This  means  of  diagnosis  and  treatment  enables  the 
surgeon  to  determine  the  number  of  kidneys  present,  and  the  relative  con- 
dition of  each,  it  being  possible  to  collect  and  analyze  the  secretion  of  each 
separately. 

To  Pawlik  belongs  the  credit  of  the  pioneer-work  in  this  field,  although 
it  had  long  since  been  suggested  by  Simon  and  Winckel.  In  Pawlik's  earlier 
work  he  practiced  direct  exploration  in  women  without  ocular  inspection  of 
the  urethral  orifices,  as  follows:  The  genitals  are  aseptized,  the  bladder 
emptied — the  urine  being  kept  for  study — and  then  refilled  with  about  6 
ounces  of  methyl-blue  solution.  The  patient  being  on  her  back  with  the 
legs  and  thighs  sharply  flexed,  a  Sims  speculum  is  introduced,  and  the  poste- 
rior wall  of  the  vagina  well  drawn  down.  Two  folds  will  be  observed  in  the 
anterior  wall,  traversing  it  about  its  middle,  and  passing  upward  and  out- 
ward upon  either  side  until  lost  in  the  vicinity  of  the  cervix.  Pawlik  terms 
these  the  ureteral  folds.  The  ureter  lies  just  above  and  parallel  with  these 
folds;  hence  the  latter  are  a  guide  to  the  ureteral  orifices.  Having  exposed 
and  made  prominent  the  ureteral  folds,  Pawlik's  urethral  sound  or  catheter 
is  now  passed  into  the  bladder,  and,  guided  by  the  folds,  is  made  to  en- 
gage in  the  ureteral  orifice.  When  this  maneuver  is  accomplished,  the 
engagement  of  the  catheter  is  announced  by  the  sensation  imparted  to  the 
hand.  The  urine  soon  trickles  through  the  catheter,  and,  being  unmixed 
with  methyl  solution,  its  origin  is  unquestionable.  A  comparative  analysis 
of  the  urine  drawn  from  each  side  may  be  made.  The  renal  pelvis  may  be 
irrigated  if  required. 

In  the  male  the  ureters  may  often  be  catheterized  by  the  aid  of  the 
cystoscope. 

Kelly  has  followed  along  the  lines  laid  down  by  Pawlik,  and  by  means 


912  DISEASES    OF    THE    UEETEE. 

of  perfected  apparatus  and  direct  inspection  of  tlie  ureteral  orifices  lias 
greatly  improved  our  facilities  for  exploration  and  treatment  of  the  ureters. 

The  following  instruments  are  required:  A  good  light  and  a  head-mir- 
ror; a  urethral  dilator;  a  speculum  with  an  ohturator;  a  suction-apparatus 
to  empty  the  bladder  completely;  a  pair  of  long  mouse-tooth  forceps;  and 
a  searcher  for  discovering  the  ureteral  orifice. 

Kelh^'s  description  of  his  method  is  as  follows: — 

A  general  anesthetic  is  not  usually  necessary,  though  it  is  sometimes  of  advantage 
to  use  ether  or  chloroform  at  the  first  examination.  If  the  urethra  requires  dila- 
tion, a  drop  of  a  10-per-cent.  solution  of  cocain  painted  on  its  external  orifice,  or  a 
piece  of  cotton  wrapped  on  an  applicator  saturated  with  a  4-per-cent.  solution  and 
laid  just  inside  the  orifice,  will  blunt  the  sensitiveness. 

Immediately  before  the  examination  the  patient  must  pass  water,  preferably  in 
the  standing  position.  In  spite  of  this,  a  little  urine  almost  always  remains.  If  the 
examination  is  delayed  ten  or  fifteen  minutes,  five  or  ten  cubic  centimeters  will  be 
added. 

The  urethral  orifice  is  dilated  with  a  conic  dilator,  blunt  at  the  point,  72 
millimeters  long,  16  millimeters  in  diameter  at  the  base  and  4  millimeters  at  the 
point.  This  is  lubricated  with  vaselin  and  gently  bored  into  the  urethral  orifice.  Two 
or  three  gentle  movements,  holding  the  dilator  poised  between  thumb  and  forefinger, 
will  be  sufficient  to  cany  it  in  as  far  as  the  number  10  mark  on  the  scale  in  its 
side.  This  indicates  a  dilation  1  centimeter  in  diameter,  sufficient  for  all  ordinary 
vesical  exploration,  treatment  of  its  surfaces,  and  catheterization  of  the  ureters. 
Often  the  orifice  needs  no  dilation  to  admit  a  speculum  of  this  size. 

I  wish  to  call  especial  attention  to  the  fact  that  dilation  of  the  external 
orifice  of  the  urethra  by  a  single  conic  dilator  is  sufficient.  The  speculum  is  a  simple 
metal  cylinder  8  centimeters  (3  inches)  long,  of  equal  diameter  from  end  to  end, 
funnel-shaped  at  its  outer  end,  with  a  long  handle  that  can  be  well  grasped,  and 
provided  with  an  obturator.  The  diameters  of' the  specula  vary  from  5  millimeters 
up  to  20  millimeters  (Vs  to  V5  inch),  shown  by  Simon  to  be  the  safe  outside  limit. 
The  sizes  most  useful  are  Xos.  8,  10,  and  11.  Xo.  8  (8  millimeters  in  diameter) 
can  be  introduced  into  almost  any  urethra  without  preliminary  dilation,  as  it  is 
scarcely  larger  than  an  ordinary  catheter.  This  is  the  size  A\hich  will  be  most  fre- 
quently used  by  the  practiced  examiner. 

The  patient  may  be  examined  either  in  the  dorsal  or  knee-breast  position.  If 
in  the  dorsal  position,  she  is  placed  on  the  table  with  legs  and  thighs  well  flexed, 
and  hips  elevated  from  15  to  30  centimeters  (6  to  12  inches)  above  the  level  of 
the  table.  If  she  be  a  thin  woman,  the  air  enters  when  the  speculum  is  introduced, 
distending  the  bladder.  But  this  will  not  succeed  with  a  fat  woman.  The  most 
convenient  and  useful  position  is  the  knee-breast  posture,  with  the  chest  as  close  to 
the  table  as  possible,  and  the  back  well  bent  in.  Frequently  a  more  satisfactory 
posture  is  the  knee-breast,  with  the  patient  squatting  a  little  backward,  so  that  the 
buttocks  are  in  a  position  directly  over  the  calves  of  the  legs  or  the  ankles,  instead 
of  being  vertically  over  the  thighs.  The  speculum  is  now  taken  in  hand,  and  held 
with  the  thumb  firmly  pressing  upon  the  handle  of  the  obturator.  The  urethral 
orifice  is  first  cleansed  with  a  boric-acid  solution.  The  point  of  the  speculum  i? 
placed  in  the  orifice  and  pushed  up  through  the  urethra  into  the  bladder  in  a  direc- 
tion describing  a  gentle  curve  around  the  under  surface  of  the  symphysis.  As  the 
speculum  is  being  introduced,  the  vulva  is  held  open  with  the  other  hand:  in 
the  case  of  a  stout  patient  the  buttocks  are  held  widely  apart  by  an  assistant.     On 


OPEKATIOXS    OX    THE    UKETEE. 


913 


withdrawing  the  obturator,  air  rushes  at  once  into  the  bladder,  distending  it  with 
an  audible  suction-sound.  If  it  is  undesirable  or  difficult  to  keep  the  patient  in 
the  knee-breast  position,  she  may  be  gently  turned  to  the  dorsal  position,  taking 
care  to  keep  the  hips  constantly  elevated  above  the  level  of  the  rest  of  the  abdomen. 
The  intestines  which  have  gravitated  out  of  the  pelvis  will  not  return  at  all,  or  but 
slowly,  as  long  as  the  hips  are  kept  thus  elevated. 

It  is  well  to  place  a  pledget  of  cotton  or  a  vessel  beneath  the  mouth  of  the  specu- 
lum to  catch  any  urine  driven  by  forcible  breathing,  coughing,  etc. 

The  examiner  wears  one  of  the  ordinary  head-mirrors  used  by  the  laryngosco- 
pists,  and  by  its  means  reflects  a  light  from  an  electric  lamp  resting  on  a  towel  on  the 
sacrum  of  the  patient  (if  in  the  knee-breast  'position),  through  the  speculum,  into 
the  bladder. 


Fig.  206. — The  Kelly  method  of  exploring  the  ureters  in  the  female: 
introduction  of  the  ureteral  catheter. 


The  trigonum  is  brought  into  view  by  m  ithdrawing  the  speculum  until  the 
internal  urethral  orifice  just  begins  to  close  over  it,  and  then  pushing  it  in  a  little  and 
dropping  the  handle  slightly.  This  portion  of  the  bladder  is,  as  a  rule,  a  little  more 
injected  and  rosy  than  the  rest  of  the  mucosa.  The  interureteric  ligament  is  some- 
times marked  as  a  distinct  rounded  transverse  fold.  By  turning  the  speculum  to 
the  right  or  left  about  thirty  degrees,  with  its  end  projecting  1  centimeter  into 
the  bladder,  the  right  and  left  ureteral  orifices  can  be  brought  successively  into  view. 
The  ureteral  orifice  usually  appears  as  a  little  slit,  about  3  millimeters  long,  placed 
transversely  with  a  slight  horseshoe-shaped  elevation  around  it,  open  oil  the  inner 
side.     Usually,  with  the  woman  in  the  knee-breast  position,  the  ureteral  orifice  is 


914 


DISEASES    OF    THE    UEETEK. 


found  on  the  inner  side  of  a  decided  eminence,  having  the  form  of  a  truncated  cone 
(mons  ureteris).  The  ureteral  orifice  may  at  times  appear  as  a  little  pit  or  hole  in 
the  mucosa,  at  other  times  as  a  rosette  with  the  opening  in  the  center.  If  the 
observation  is  continued  for  a  minute  a  little  jet  of  urine  will  be  seen  to  spurt  out 
of  the  ureter  for  two  or  three  seconds.  The  ureter  then  closes  to  be  opened  by 
another  jet  within  the  following  minute.  I  have  repeatedly  seen  pus  or  blood 
escaping  from  one  ureter,  while  clear  urine  escaped  from  its  fellow. 

Sounding  and  Catheterizing  the  Female  Ureters. — The  passage  of  a  catheter, 
sound,  or  bougie  into  the  ureter  is  as  easily  accomplished  as  the  inspection  of  its 
orifice,  and,  if  gently  conducted,  is  a  simple,  painless,  and  harmless  procedure.  I  have 
found  it  necessary  under  a  variety  of  conditions,  the  most  important  of  which  may 
be  classified  under  the  following  headings:  — 


Fig.  207. — Ureteral  catheter  in  position.     (After  Kelly.) 


First,  for  the  collection  of  urine  directly  from  the  ureter,  without  contamination 
with  the  bladder-urine,  in  order  to  determine  the  presence  or  absence  of  renal  disease, 
or  of  one  kidney  and  not  of  the  other. 

Second,  to  determine  the  existence  of  ureteral  disease,  such  as  hydro-ureter  and 
pyo-ureter. 

Third,  in  order  to  lay  a  solid  bougie  in  the  ureter,  so  that  it  can  be  kept  con- 
stantly under  touch  and  recognized  throughout  any  abdominal  or  pelvic  operation  in 
which  it  is  in  danger  of  being  cut  or  tied. 

For  a  ureteral  catheter,  I  use  a  simple  metal  tube  about  25  centimeters  (10 
inches)  long,  gently  curved  at  its  outer  end,  which  is  held  in  the  hand,  so  as  not  to 
obstruct  the  view  during  its  introduction.  The  end  is  also  enlarged  a  little,  so  as  to 
hold  a  fine  rubber  tube  slipped  over  it  in  washing  out  the  ureter  and  kidney.     The 


OPEKATIONS  ON  THE  UEETEK.  915 

ureteral  end  of  the  catheter  has  a  rounded  point  with  three  or  four  holes  in  it  and 
a  very  slight  curve  at  the  end. 

To  introduce  the  catheter,  the  ureteral  orifice  is  brought  to  about  the  center 
of  the  field  of  the  speculum,  and  the  mirror  and  light  are  adjusted  so  that  the  head 
of  the  observer  is  not  in  the  way  as  he  introduces  the  catheter  into  the  speculum  and 
slides  it  on,  until  its  point  rests  in  the  ureteral  slit.  On  pushing  it  in  a  little,  the 
sides  of  the  opening  separate,  and  it  appears  as  a  hole,  with  the  catheter  lying  in 
one  side  of  it.  The  catheter  must  now  be  pushed  out  gently  toward  the  side,  stopping 
at  once  if  the  slightest  resistance  or  obstruction  is  met.  When  it  has  reached  the 
pelvic  wall,  4  or  5  centimeters  (IV2  to  2  inches)  from  the  orifice,  it  must  be  firmly 
held  while  the  speculum  is  slowly  drawn  out,  disengaged  from  the  urethra,  and 
pulled  over  its  end.  It  is  usually  necessary  for  an  assistant  to  pull  open  the 
buttock  of  the  side  on  which  the  handle  lies,  to  keep  it  from  making  such  undue 
pressure  upon  the  ureteral  catheter  as  may  injure  the  ureter.  The  patient  who  has 
been  in  the  knee-breast  position  may  now  raise  herself  upon  her  elbows  or  hands, 
while  the  urine  is  being  collected  as  it  flows  from  the  catheter.  A  minute  or  two, 
or  more,  often  elapses  before  the  flow  begins.  It  is  easy  to  tell  whether  the  catheter 
is  filling  by  stopping  up  its  end  with  a  little  drop  of  water,  which  blows  out  in 
the  form  of  a  little  bubble  as  soon  as  there  is  any  movement  within.  The  urine 
escapes  intermittently  by  three,  four,  or  five  drops,  one  after  the  other,  followed  by 
a  pause  of  from  a  few  seconds  to  a  half-minute  or  more.  The  average  amount  of 
the  flow  should  be  ^/o  cubic  centimeter  (Vs  dram)  per  minute.  It  is  often  less 
than  this,  but  rarely  more,  unless  there  is  some  disease.  I  have  in  a  number  of 
instances  seen  the  urine  escape  from  the  catheter  in  a  steady  stream,  but  they 
were  all  cases  of  hydro-ureter. 


PART  X. 

DISEASES  OF  THE  TESTIS  AXD  SPEEMATIC  COED. 


CHAPTEE  XXXIX. 

DISEASES  OF  THE  SCROTUM,  TESTIS,  AXD  SPERMATIC  CORD. 

A-NATOMT  OF  THE  TESTIS  AND  COED;  DISEASES  OF  THE  ScEOTUM;  ANOM- 
ALIES OF  THE  Testis;  Teaumatisms  of  the  Testis;  Hematocele; 
Malignant  •  Disease  of  the  Sceotum;    Lymph-sceotum. 

anatomy  of  the  testes. 

The  testes  are  two  small,  ovoid,  glandular  bodies  the  function  of  which 
is  to  elaborate  the  seminal  fluid.  They  are  situated  in  the  scrotal  pouch, 
one  in  each  lateral  compartment.  Their  investments  comprise  several  im- 
portant structures,  viz.:  the  integument  and  dartos  muscle,  constituting 
the  scrotum;-  the  intercolumnar  fascia,  the  cremaster  muscle,  the  infundib- 
uliform  fascia,  and  the  tunica  vaginalis  testis.  All  these  investments, 
the  scrotum  excepted,  are  brought  down  b}^  the  testes  in  their  descent 
during  fetal  life.  Of  these  various  coverings  the  tunica  vaginalis  is  the 
most  interesting  surgically.  The  others  are  of  interest  only  as  details  of 
descriptive  anatomy  and  in  relation  to  hernia.  The  arrangement  of  the 
testes  by  which  one  hangs  lower  than  the  other  is  useful  in  preventing 
the  organs  from  being  compressed  together  and  thereby  injured. 

The  spermatic  cord  occupies  the  inguinal  canal  upon  either  side.  It 
is  composed  of  the  spermatic  arteries,  veins,  and  nerves,  lymphatics,  and 
the  excretory  duct  of  the  testicle,  the  vas  deferens,  these  structures  being 
l)ound  together  by  cellular  tissue.  The  spermatic  veins  form  a  plexus  con- 
stituting the  chief  mass  of  the  cord;  this  is  known  as  the  pampiniform 
plexus,  and  is  of  great  importance  in  connection  with  the  subject  of  varico- 
cele. •  The  arteries  of  the  testicle  and  cord  are  derived  in  part  from  the 
13udic  branches  of  the  femoral  and  the  cremasteric  branch  of  the  epigastric; 
the  spermatic  artery  comes  from  the  aorta,  and  the  artery  of  the  vas  deferens 
from  the  superior  vesical.  The  testis  is  ovoid  in  form,  flattened  laterally, 
and  measures  one  and  a  half  to  two  inches  in  length,  one  inch  in  width, 
and  one  and  a  quarter  inches  in  thickness.  It  is  composed  of  two  portions, 
the  hody  and  the  epididymis,  and  is  covered  by  three  coats,  the  tunica  vagi- 
nalis (visceral  layer),  tunica  alhuginea.  and  tunica  vasculosa. 

The  epididymis  is  an  elongated  body  composed  of  a  convoluted  tube  of 
considerable  size;  this  structure  is  attached  longitudinally  to  the  posterior 
body  of  the  organ,  and  presents  a  central  portion  or  bod}^,  a  superior  glob- 
(916) 


AXATOMY    OF    THE    TESTES. 


917 


ular  enlargement  or  head — the  globus  major,  and  an  inferior  expansion — 
the  globus  minor,  the  latter  corresponding  to  the  tail  of  the  structure.  The 
testicle  is  infolded  by  the  tunica  vaginalis  in  precisely  the  same  manner  as 
is  the  lung  by  the  pleura.  It  does  not  lie  in  the  sac,  but  outside  of  it,  and 
is  closely  invested  by  its  visceral  layer. 

The  tunica  alhuginea  is  the  outer  dense  tibro-elastic  coat  of  the  testis, 
the  tunica  vasculosa  or  pia  mater  testis  lying  just  beneath  it.  The  density 
of  the  tunica  albuginea  is  of  especial  interest  and  importance,  as  it  not  only 
affords  a  strong  protection  for  the  seminal  tubules,  but,  unfortunately,  when 
the  testis  is  inflamed  gives  rise  by  counter-pressure  to  great  pain  and  often 
gangrene. 


Fig.  208.— Dissection  of  testis.     (After  Gray.) 


The  interior  of  the  testicle  is  divided  by  a  fibrous  partition,  the  medi- 
astinum testis.  From  this  septum  numerous  prolongations  or  trabeculas  are 
given  off  into  the  interior  of  the  organ;  these  septa,  with  the  mediastinum, 
serve  to  retain  the  form  of  the  testicle  and  support  the  blood-vessels  and 
lobules  of  the  organ. 

The  glandular  structure  of  the  testis  is  arranged  in  lobules,  their  num- 
ber being  variously  estimated  at  from  250  to  400.  Each  lobule  consists  of 
from  1  to  3  convoluted  tubules,  the  tubuli  seminiferi,  measuring  ^/^oo  'to 
^/i.:;o  iiich  in  diameter,  and  about  1(5  feet  in  length.  At  the  apices  of  the 
seminal  lobules  these  tubes  become  straight,  forming  the  vasa  recta;  these 
are  about  ^/go  inch  in  diameter.  .  At  the  upper  and  back  part  of  the  testis 


918  DISEASES    OF    THE    SCEOTUM. 

the  vasa  recta  form  a  close  net-work  called  the  r&te  testis,  the  vessels  of 
which  finally  converge  into  15  to  20  tubes  called  the  vasa  ejferentia.  These 
vessels,  at  first  straight,  become  enlarged  and  convoluted,  forming  the 
coni  vasculosa,  and  constituting  the  globus  major  of  the  epididymis. 

The  vas  deferens  is  the  continuation  of  the  epididymis;  it  passes  up- 
ward in  the  spermatic  cord  to  the  external  ring,  along  the  inguinal  canal 
to  the  internal  ring,  and  from  thence  over  the  side  and  back  of  the  bladder 
to  its  base,  where  it  combines  with  the  ducts  of  the  vesiculce  seminales  to 
form  the  ejaculatory  duct  upon  each  side,  opening  on  the  floor  of  the  pro- 
static urethra. 

The  seminal  vesicles  are  two  lobulated  membranous  pouches  situated 
upon  each  side  of  the  base  of  the  bladder,' between  that  viscus  and  the 
rectum;  they  serve  as  reservoirs  for  the  temporary  storage  of  semen,  and 
secrete  a  fluid  that  dilutes  and  increases  the  bulk  of  the  seminal  secretion. 

DISEASES    OF    THE    SCKOTrM. 

The  first  subject  for  consideration  in  studying  the  diseases  of  the 
testis  is  naturally  those  morbid  conditions  affecting  the  scrotum  or  external 
envelope  of  the  organ.  It  is  not  the  author's  intention,  however,  to  dis- 
cuss these  dermal  lesions  exhaustively;  in  the  majority  of  cases  they  more 
properly  belong  to  the  department  of  dermatology. 

Eczema  of  the  Sceotum. — Scrotal  eczema  is  quite  frequently  seen, 
and  may  or  may  not  be  associated  with  eczema  of  the  penis.  Most  usually 
the  thighs  and  groins  are  involved.  There  are  certain  peculiarities  of  text- 
ure and  situation  that  make  the  scrotum  peculiarly  liable  to  superficial 
inflammation.  The  coarse  hairs  upon  its  surface  favor  irritation  and  un- 
cleanliness;  the  sebaceous  glands  are  large  and  afford  a  readily  decompos- 
able secretion;  the  sudoriparous  glands  are  numerous  and  active,  and  in 
some  subjects  the  parts  are  with  difficulty  kept  dry.  The  close  contact  of 
the  scrotum  with  the  thighs  and  perineum  favors  sensitiveness  of  the  in- 
tegument, and  the  friction  produced  by  the  thighs  and  clothing  in  the 
movements  of  the  body  enhances  any  irritation  that  may  exist.  These  cir- 
cumstances explain  why  eczema  of  the  scrotum  is  frequently  seen,  and, 
moreover,  why  it  is  likely  to  prove  a  troublesome  affection.  The  disease  is 
not  unlike  the  form  that  occurs  in  other  situations,  there  being,  perhaps, 
a  greater  tendency  to  excoriation  and  serous  exudation  from  the  inflamed 
surface.  Itching  and  smarting  are  severe,  and  in  some  cases  make  the  life 
of  the  patient  miserable.  The  warmth  of  the  part,  and  the  conditions 
already  alluded  to,  in  connection  with  the  various  bodily  movements  ex- 
plain this  very  annoying  symptom. 

Treatment. — The  treatment  of  scrotal  eczema  should  be  conducted 
upon  the  same  general  principles  that  guide  us  in  the  management  of  the 
aft'ection  in  other  locations.     Especial  care  should  be  taken  to  keep  the 


PHTHIRIASIS.  919 

parts  dry  and  prevent  friction  against  the  thighs.  The  application  of  a 
well-fitting  suspensory  bandage  of  light  texture — silk  and  rubber  being 
avoided  as  too  heating — and  the  plentiful  use  of  drying  powders,  with  the 
occasional  application  of  astringent  washes,  constitute  the  principal  meas- 
ures of  treatment.  In  chronic  cases  the  administration  of  arsenic  and 
tonics,  such  as  codliver-oil  and  iron,  may  be  required. 

Phthiriasis — Louse  Disease. — A  very  frequent  cause  of  scrotal  irri- 
tation that  may  lead  to  eczema  is  the  Pediculus  pubis,  or  crab-louse.  This 
insect  does  not  limit  itself  to  the  scrotum,  but  infests  the  hairs  about  the 
pubes,  thighs,  and  groins,  and  in  neglected  cases  all  other  parts  of  the  body. 
It  is  not  unusual  in  hospital  patients  to  find  the  hairs  of  the  axillse,  and  even 
the  eyebrows,  thickly  incrusted  with  this  form  of  pediculi.  They  can  be  de- 
tected readily  with  the  naked  eye,  and  are  usually  to  be  found  at  the  roots 
of  the  hairs,  being  sometimes  detached  with  difficulty.  Upon  superficial 
examination  they  may  be  mistaken  for  small  crusts  or  scales.  Their  ova  or 
nits  will  be  found  scattered  around  in  plentiful  profusion,  resembling  little 
buds  upon  the  shafts  of  the  hairs.  The  pediculi  produce  intense  irritation, 
particularly  when  the  body  is  warm,  the  annoyance  being  greatly  increased 
after  the  patient  becomes  warm  in  bed.  So  frequent  is  this  little  insect 
that  its  existence  should  always  be  suspected  in  cases  of  irritation  and 
itching  about  the  genitals.  Some  very  absurd  mistakes  are  occasionally 
made  in  such  cases.  The  author  recalls  the  case  of  a  gentlemen  who  had 
been  treating  for  some  time  for  what  had  been  termed  by  his  physician  ^'liver 
complaint,"  the  symptoms  of  which  were  intense  itching  about  the  genitals. 
The  patient,  being  very  cleanly  in  his  habits,  had  no  suspicion  of  the  exist- 
ence of  vermin.  He  was  in  the  habit  of  taking  a  Turkish  bath  once  or  twice 
a  week,  but  his  ordinary  measures  of  bodily  cleanliness  failed  to  remove  these 
closely-clinging  insects,  and  gave  no  relief  from  the  irritation.  His  phy- 
sician had  given  him  an  elaborate  dissertation  upon  the  functions  of  the 
liver  and  the  vicarious  action  of  the  skin,  with  the  interesting  explanation 
that  the  materials  thrown  out  by  the  skin  as  a  consequence  of  perturbation 
of  the  function  of  the  liver  were  irritating  the  cutaneous  nerves.  The  pa- 
tient was  considerably  shocked,  as  well  as  disgusted  with  doctors  in  gen- 
eral, when  the  existence  of  the  parasite  was  demonstrated  to  him. 

Phthiriasis  may  be  contracted  by  the  most  cleanly  persons,  although 
filth  obviously  favors  the  development  of  the  vermin.  Public  closets  are  usu- 
ally the  means  of  conveyance.  Public  swimming-baths  are  a  not  infrequent 
source  of  pediculi.  Should  a  person  affected  by  them  sleep  with  another, 
the  latter  will  inevitably  receive  a  colony  of  lice.  The  street-car  is  also  a 
means  of  disseminating  the  vermin. 

Treatment. — The  treatment  of  the  affection  consists  in  the  application 
of  parasiticides,  the  most  popular  of  which  is  mercurial  ointment.  Al- 
though this  remedy  is  effectual,  it  is  somewhat  objectionable  on  the  ground 
of  offensiveness.     A  5-  to  10-per-cent.  ointment  of  oleate  of  mercury  is 


920  DISEASES    OF    THE    SCKOTUM. 

very  satisfactory.     An  ointment  of  the  red  oxid  of  mercury  is  also  effica- 
cious.   The  following  lotion  is  an  excellent  remedy: — 

li.  Hydrarg.  bicliloridi gr.  xij. 

Tr.  staphysagrise Siv. 

Sig. :     Lotion.     Apply  night  and  morning. 

Frequent  bathing  is  necessar3\  The  hair  should  be  clipped  from  the 
parts  to  remove  the  ova  of  the  vermin,  so  far  as  possible,  and  treatment 
should  be  kept  up  for  several  weeks  for  the  purpose  of  destroying  such 
vermin  as  may  hatch  in  the  meantime. 

Caxcee  of  the  Sceotu:m. — This  form  of  malignant  disease  is  usually 
of  the  epitheliomatous  variety.  It  is  generally  associated  with  malignant 
disease  of  the  penis,  and  hence  does  not  require  separate  discussion.  There 
is  a  variety  of  cancer  of  the  scrotum  exhaustively  described  in  some  works 
upon  surgery,  particularly  those  of  the  older  authors,  known  as  "chimney- 
sweeps' cancer."  This  is  dtte  to  irritation  produced  by  the  soot  that  is  de- 
posited upon  the  scrotum  of  the  chimney-sweep  in  his  vocation.  The  dis- 
ease was  formerly  cjuite  frequent,  as  might  be  inferred  from  its  special 
nomenclature,  but  as  the  honorable  body  of  chimney-sweeps  has  rapidly 
diminished  pari  passu  with  the  introduction  of  certain  modern  improve- 
ments, the  disease  is  now  infrecjuently  seen,  even  in  England,  where  it  was 
first  described. 

Treatment. — The  treatment  of  cancer  of  the  scrotum  consists  in  com- 
plete excision. 

Elephantiasis  Scroti,  oe  Ltmph-sceotum.  —  This  is  an  affection 
rarely  seen  save  in  tropic  countries.  It  may  be  associated  with  elephantiasis 
of  other  parts,  but  is  likely  to  be  met  with  as  an  independent  disease.  The 
scrotal  tissues  may  be  enormously  enlarged. 

The  disease  consists  essentially  of  occlusion  of  the  lymph-channels  of 
the  scrotum.  This  is  apparently  the  result  of  some  specific  type  of  inflam- 
mation. Ordinary  inflammation  will  not  cause  it,  though  it  often  produces 
chronic  hyperplasia  and  considerable  scrotal  redundancy.  It  has  been 
claimed  that  lymph-scrotum  and  elephantiasis  are  due  to  a  parasite,  the 
Filaria  sanguinis  Jiominis,  met  with  in  tropic  countries.  The  parasite  and 
lymph-scrotum  are  so  frequently  associated  that  this  etiologic  deduction 
seems  warrantable. 

Symptoms. — Lymph-scrotum  is  ushered  in  by  an  acute  inflammation 
resembling  erysipelas.  The  acute  symptoms  subsiding  after  a  time,  the  part 
is  left  permanently  enlarged.  Congenital  occlusion  of  lymph-channels  with 
resulting  lymph-scrottim  have  been  observed. 

Treatment.  —  Measures  directed  against  acute  inflammation  are  indi- 
cated in  the  incipiency  of  the  disease.  Once  the  characteristic  chronic  en- 
largement has  been  established,  excision  is  the  only  recourse. 

The  other  cutaneous  affections  of  the  scrotum  are  similar  to,  and  most 


i 


ANOMALIES   AND    CONGENITAL    DEFORMITIES    OF    THE    TESTIS.  921 

often  associated  with,  those  affecting  the  penis;   hence  do  not  require  sep- 
arate discussion. 

Eedundancy  of  THE  ScEOTUM. — ThJs  Condition  is  of  surgical  impor- 
tance only  in  connection  with  varicocele. 

ANDMALIES   AND   CONGENITAL  DEFOEMITIES    OF   THE   TESTIS. 

These  are  few  in  number,  and  of  little  practical  importance  because 
of  their  rarity  and  the  infrequency  with  which  they  demand  surgical  in- 
terference. 

There  is  a  popular  notion  that  individuals  exist  who  are  the  fortunate 
possessors  of  an  extra  testis,  but  these  alleged  supernumerary  glands  have 
been  found  on  dissection  to  consist  of  fibrous,  cystic,  fatty,  or  some  other 
variety  of  tumor.     It  is  probable  that  the  "third  testicle"  is  a  myth. 


Fig.  209. — Elephantiasis  scroti.     (After  Aston  Key.) 

One  or  both  testes  may  be  absent,  these  cases  constituting  monorchid- 
ism  and  cryptorchidism — terms  that  sufficiently  explain  themselves.  In  such 
cases  the  testes- — one  or  both — are  retained  within  the  abdomen.  As  the 
testis  descends  from  its  fetal  location,  it  may  be  arrested  at  any  point  in  its 
course.  It  is  developed  during  intra-uterine  life  at  a  point  corresponding 
with  the  inferior  extremity  of  the  kidney,  behind  the  peritoneum.  From 
this  situation  it  slowly  descends  until  at  term  it  occupies,  under  normal 
circumstances,  the  scrotal  pocket  provided  for  it.  As  it  descends,  guided  by 
the  guhernaculum  testis,  the  organ  carries  with  it  a  fold  of  peritoneum  that 
subsequently  constitutes  the  tunica  vaginalis,  or  serous  coat  of  the  testis. 
Instead  of  being  checked  in  its  downward  course,  the  organ  may  take  an 
erratic  course  and  enter  the  femoral  canal,  or  appear  in  the  perineum.  In 
the  first  event  it  may  be  mistaken  for  femoral  hernia,  neoplasmic  forma- 
tions, or  abscess;  in  the  perineum,  especially,  it  is  liable  to  be  mistaken  for 


922  ANOMALIES   AND    CONGENITAL    DEFORMITIES    OP   THE    TESTIS. 

abscess.  In  cryptorchidism,  as  a  rule,  the  testis  stops  in  the  inguinal  canal; 
but  in  all  cases  of  the  kind  every  possible  site  of  the  testes  should  be  ex- 
amined. Cases  of  cryptorchidism  are  sometimes  cured  spontaneously  by 
the  descent  of  the  testes  after  birth,  cases  having  been  recorded  in  which 
some  years  elapsed  before  descent  occurred.  In  some  cases  the  contents  of 
the  abdomen  have  followed  the  testis  in  its  descent,  and  formed  a  hernia; 
in  others  the  canal  that  is  left  serves  for  the  passage  of  serous  fluid,  with 
resultant  congenital  hydrocele. 

As  a  rule,  retained  testes  never  develop,  and  the  individual  is  sterile. 
He  is  not  necessarily  impotent,  however,  as  erections  and  emissions  are 
possible;  but  the  question  of  sterility  is  only  to  be  settled  by  microscopic 
examination  of  the  seminal  fluid.  When  but  one  organ  is  retained  the 
other  undergoes  a  compensatory  change  and  does  duty  for  two,  as  when 
one  testis  is  removed  by  castration  or  injury. 

The  results  of  retained  testis  are  variable.  Sometimes  there  is  little 
or  no  discomfort,  and  the  patient  does  not  bother  himself  about  his  condi- 
tion; often,  on  the  other  hand,  it  gives  rise  to  pain  in  locomotion  due  to 
the  pressure  of  the  fibrous  and  tendinous  structures  of  the  canal  upon  it. 
It  may  suddenly  inflame, — this  has  been  known  to  occur  in  gonorrhea, — 
giving  rise  to  nausea,  vomiting,  faintness,  and  other  symptoms  of  strangula- 
tion of  tissue;  this  condition  may  be  mistaken  for  strangulated  hernia. 

Experience  has  demonstrated  the  liability  of  retained  testis  to  undergo 
malignant  degeneration.  This  is  advanced  as  a  cogent  argument  in  favor 
of  its  removal.  This  tendency  to  malignant  transformation  is  not  difficult 
of  explanation  if  we  accept  the  most  logical  of  the  theories  thus  far  advanced 
regarding  the  origin  of  cancer.  It  is  obvious  that  the  arrest  in  the  descent  of 
the  testis  is  necessarily  accompanied  by  arrested  differentiation  of  its  struct- 
ure. In  direct  proportion  to  the  approximation  of  the  organ  to  its  primary 
embryonic  structure  is  its  intrinsic  liability  to  development  of  neoplastic 
growth  under  proper  stimulus.  Such  stimulus  is  afforded  by  the  pressure 
and  movement  of  the  contiguous  dense  structures  upon  the  rudimentary 
testis.  In  common  with  all  highly-complex  glandular  structures,  the  testis, 
if  it  responds  to  the  irritation  at  all,  is  most  apt  to  do  so  by  malignant 
change.  Cohnheim's  theory  implies  that  there  exists  in  many  individuals 
a  predisposition  to  the  development  of  neoplasia  (particularly  to  those  of  a 
cancerous  character)  in  the  form  of  embryonal  tissue-elements  that  have 
failed  to  become  differentiated  and  consequently  remain  imperfectly  de- 
veloped. These  embryonal  cells  have  within  them  the  elements  of  rapid 
growth,  for,  seemingly,  the  rapidity  of  development  of  cells  is  in  inverse 
proportion  to  their  degree  of  differentiation.  All  that  is  necessary  is  the 
occurrence  of  an  exciting  cause  (in  the  form  of  an  injury  to  the  tissues)  to 
develop  the  potential  proliferating  energy  of  these  embryonal  elements  of 
tissue  with  resulting  formation  of  a  tumor.  The  more  characteristically 
embryonal  the  cells,  the  greater  the  tendency,  first,  to  malignant  forma- 


HYPERTROPHY   AND   ATROPHY    OF    THE    TESTIS.  923 

tion,  and,  second,  to  general  infection  of  the  system  by  the  resulting  prod- 
uct. Not  only  is  the  rapidity  of  development  of  these  cells  in  direct  pro- 
portion to  their  degree  of  differentiation,  but  their  tendency  to  retrograde 
change  and  to  infection  of  the  glandular  and  general  system  is  also  pro- 
portionate to  their  degree  of  approximation  to  the  primal  embryonal  type. 
As  already  suggested,  a  similar  explanation  may  perhaps  account  for  the 
■development  of  sarcoma  and  carcinoma  in  the  kidneys  of  young  subjects. 
Such  growths  develop  usually  in  young  children,  and  it  would  seem  that  the 
persistence  of  embryonal  elements  in  the  kidney  would  afford  a  logical  ex- 
planation for  this  fact. 

Treatment. — The  treatment  of  retained  testis,  when  unilateral,  in  view 
of  the  danger  of  carcinoma,  should  be  radical  in  the  majority  of  cases.  Ex- 
tirpation is  usually  the  proper  method  of  procedure,  as  operations  for  reposi- 
tion of  the  organ  are  rarely  successful.  Even  if  it  be  practicable  to  bring  the 
organ  down  into  place  and  retain  it  there,  the  operation  is  hardly  worth  while, 
as  the  gland  is  of  degenerate  type  with  a  propensity  for  pathologic  changes 
that  overbalances  any  possible  normal  functional  capacity.  In  some  excep- 
tional cases  an  attempt  may  be  made  to  gradually  push  the  testis  down  to 
its  place  in  the  scrotum  by  pressure  and  manipulation.  If  reduction  can  be 
easily  accomplished,  fixation  of  the  cord  by  operation  is  warrantable  and 
may  be  necessary  to  prevent  the  organ  from  again  becoming  displaced. 
Whenever  a  retained  testicle  is  troublesome  it  should  be  removed  without 
delay.  When  cryptorchidism  is  bilateral,  the  testes  had  best  be  let  alone  un- 
less some  special  indication  arises. 

HYPERTROPHY  AND  ATROPHY   OF   THE   TESTIS. 

These  conditions  are  not  of  great  importance.  The  former  is  usually 
met  with  as  a  compensatory  physiologic  condition:  e.g.,  where  one  organ 
has  been  removed  by  operation  or  disease.  The  size  of  the  testes  varies 
greatly  within  physiologic  limits  in  different  subjects.  This  variation, 
especially  if  it  be  in  the  direction  of  diminutiveness,  may  be  the  basis  of 
sexual  psychopathic  states  in  which  moral  persuasion  to  restore  confidence 
is  the  chief  indication. 

Atrophy  may  be  congenital,  but  it  is  to  be  remembered  that  mere  size 
is  by  no  means  a  criterion  of  the  inherent  organic  strength  and  functional 
capacity  of  the  testes.  The  atrophy  may  be  only  apparent,  not  real,  as 
shown  by  structural  firmness  of  the  organs  as  well  as  by  sexual  vigor. 
Atrophy  is  often  the  result  of  disease  or  traumatism.  Parotiditis  is  the 
most  frequent  cause.  Varicocele  is  accompanied  by  nutritional  disturbance 
of  the  testis  of  the  affected  side,  which  may  result  in  atrophy. 

Treatment.- — Hypertrophy  requires  no  attention.  Atrophy  demands 
the  faradic  current  and  massage,  improvement  occurring  in  a  small  pro- 
portion of  cases.  The  danger  of  atrophy  should  be  duly  considered  in  all 
inflammatory  conditions  of  the  testis,  and  the  foregoing  treatment  adopted 


924  TRAUMATISMS    OF    THE    TESTIS. 

early  as  a  prophylactic  measure.  Operations  for  varicocele  in  successful 
eases  are  likely  to  be  followed  b}^  improyement  in  nutrition  and  develop- 
ment of  the  testicle  involved.  As  a  rule,  atrophy  of  the  testis  means  de- 
struction of  its  glandular  structure;   hence  the  ineihcacy  of  treatment. 

TRArMATISMS    OF   THE   TESTIS. 

Injuries  of  the  testicle  are  rarely  presented  to  the  notice  of  the  sur- 
geon. The  testicle,  like  the  pendulous  portion  of  the  penis,  is  a  very 
elusive  structure  and  keeps  out  of  the  way  of  injury.  Contusions  are  more 
often  seen  than  wounds,  and  usually  result  from  kicks  or  falls  upon  the 
stride.  The  author  recalls  one  severe  case  produced  b}'  a  blow  Avith  a  base- 
ball. 

The  testicle  being  an  exquisitely  sensitive  organ,  the  pain  and  shock 
produced  by  its  injury  are  very  pronounced.  Most  men  are  familiar  with 
the  depressing  effect  of  even  a  slight  blow  upon  the  testes.  ISTausea,  vom- 
iting, and  even  muscular  spasms  or  general  convulsions  may  result  from 
severe  injuries.  The  local  effects  of  contusions  are  quite  marked.  Severe 
ecchymosis  is  usual  on  account  of  the  looseness  of  the  scrotal  tissues. 
Hematocele  may  come  on  immediately  from  rupture  of  the  spermatic  veins. 
Inflammation  from  infection  often  follows,  and  this  has  been  known  to 
result  in  sloughing  and  abscess. 

Treatment. — The  treatment  involves  the  usual  surgical  principles. 
Contusions  require,  primarily,  rest  and  the  application  of  ice-bags,  to  pre- 
vent further  effusion  and  inflammation.  "When  the  danger  of  inflamma- 
tion has  passed,  hot  water  and  strapping  are  indicated  to  promote  resolu- 
tion. If  the  injur}'  also  involves  the  urethra,  the  treatment  should  com- 
prise those  measures  advised  in  the  chapter  on  urethral  traumatisms.  "When 
the  testis  has  been  wounded,  antiseptic  sutures  and  dressings  and  subse- 
quent rest  are  required.  If  the  glandular  structure  is  protruding,  the  sur- 
geon should  not  pull  upon  it,  else  he  will  accomplish  a  result  similar  to  that 
obtained  by  the  man  who  undertakes  to  mend  his  own  watch,  and  have 
material  enough  to  fill  several  cavities  the  size  of  the  scrotum.  The  pro- 
trusion should  be  carefully  reduced  and  retained  by  pressure  or  suture. 
If  this  cannot  be  accomplished,  it  should  be  removed  with  scissors. 

HEMATOCELE  OF  THE   TESTIS  AND  TUXICA  VAGINALIS. 

This  bears  a  most  intimate  relation  to  trauma  of  the  testis,  and  is  one 
of  its  most  formidable  results.  The  term  hematocele  is  a  comprehensive 
one  and  includes  all  tumors  produced  b}'  effusion  of  blood  about  the  testis, 
whether  into  the  tunica  vaginalis  of  the  testis  and  cord  with  accompanying 
scrotal  effusion,  or  into  a  pre-existing  cyst  or  hydrocele  in  this  situation. 

Etiology. — The  causes  of  hematocele  are  of  a  traumatic  character,  as 
a  rule,  injuries  involving  the  blood-vessels  being  the  usual  cause.     Some- 


I 


HEMATOCELE    OF    THE    TESTIS    AXD    TUXICA    YAGIXALIS. 


925 


times  the  testicle  or  its  veins  are  wounded  in  puncturing  a  hydrocele,  with 
consequent  hematocele  of  the  sac.  A  very  slight  injury  may  cause  hemat- 
ocele in  cases  of  varicose  enlargement  of  the  pampiniform  plexus:  i.e., 
varicocele.  A  severe  strain^  as  in  lifting,  has  heen  known  to  produce  it  in 
such  cases.  Earely  scurvy  or  purpura  may  cause  hematocele  without  inter- 
vention of  trauma.  Any  disease  producing  morbid  changes  in,  and  weak- 
ness of,  the  blood-vessels  predisposes  to  hematocele. 

Varieties. — From  what  has  been  said  of  its  causes,  it  may  be  readily 
understood  that  the  disease  occurs  in  two  forms.  1.  In  the  most  common 
variety  the  tumor  forms  immediately  after  a  wound  or  other  injury,  either 


Fig.  210. — Hematocele  of  the  tunica  vaginalis.     (After  Dupuytren.) 


as  a  sudden  development  in  tissues  previously  normal  or  a  sudden  increase 
in  size  of  a  pre-existing  hydrocele  or  cyst.  The  scrotum  almost  immediately 
becomes  of  a  dark-bluish  or  black  color  from  extravasated  blood.  More  or  less 
fever  is  usual,  and  is  due  to  shock  and  nervous  irritation  in  the  simple  eases; 
if  suppuration  supervenes,  the  fever  may  be  marked;  in  some  instances  true 
septic  fever  occurs. 

2.  The  rarer  form  of  hematocele  comes  on  either  spontaneously  or 
after  very  slight  injuries,  being  of  such  slow  and  gradual  development  that 
it  can  only  be  distinguished  from  hydrocele  by  its  opacity. 

On  section,  the  cavity  of  an  hematocele  may  be  found  filled  with  black 
or  brown  partly  disorganized  blood,  sometimes  clotted,  but  generally  fluid; 


926  HEMATOCELE    OF    THE    TESTIS    AND   TUNICA   VAGINALIS. 

.occasionally  red  and  fluid,  and,  if  inflammation  be  high,  mixed  with  pus. 
Important  changes  are  apt  to  occur  in  the  walls  of  an  hematocele,  these  bear- 
ing a  close  similarity  to  those  occurring  in  aneurism:  i.e.,  stratification  and 
semi-organization  of  blood-clot  (fibrin),  with  subsequent  marked  thicken- 
ing and  perhaps,  calcareous  degeneration. 

Diagnosis. — The  diagnosis  of  hematocele  is  not  always  a  simple  mat- 
ter, although  usually  easy  enough  in  the  acute  traumatic  variety.  In  the 
more  passive  spontaneous  variety  mistakes  in  diagnosis  are  very  frequent; 
indeed,  cases  are  on  record  in  which  healthy  testes  were  removed  along  with 
an  hematocele  under  the  idea  that  the  tumor  was  a  cancerous  or  sarcom- 
atous growth.  This  fact  has  impelled  conservative  surgeons  to  cut  into 
every  tumor  of  the  testicle  before  removing  it.  Very  often  an  exploratory 
incision  will  be  foimd  necessary  for  diagnostic  purposes,  as  there  is  no  his- 
tory of  traumatism,  rapid  development  of  a  tumor,  scrotal  discoloration,  etc., 
to  guide  us.  It  is  a  safe  rule  to  explore  tumors  of  the  testicle  before  re- 
moval, to  see  whether  we  may  not  be  dealing  with  an  old  hematocele  with 
thickened  walls.  An  hematocele  is  of  the  same  pyramidal  shape  as  a  hydro- 
cele, but  differs  from  it  in  being  opaque  and  very  heavy  by  comparison;  an 
old  hydrocele  with  thickened  walls,  however,  may  be  quite  as  opaque  as 
an  hematocele.  In  all  cases  the  history  of  the  disease  is  all-important  in  the 
diagnosis,  especially  in  differentiating  from  cancer.  At  some  time  during 
the  early  history  of  hematocele  it  undergoes  a  certain  amount  of  shrinkage 
and  consequent  diminution  in  size;  this  is  not  true  of  cancer  and  other 
solid  tumors  of  the  testis.  Syphilitic  tumors  will  disappear  under  proper 
treatment,  and  such  treatment  should  always  be  instituted  in  cases  of  doubt. 

Pressure  upon  the  back  of  the  tumor  may  elicit  the  peculiar  sensation 
experienced  when  the  testicle  is  squeezed. 

The  exploring  needle  or  aspirator  may  give  negative  results,  but  the 
trocar  will  usually  determine  the  nature  of  the  tumor;  if  not,  we  are  justi- 
fied in  resorting  to  incision. 

Treatment. — The  treatment  of  hematocele  is  very  simple  in  acute  cases, 
rest,  ice-bags,  and  anodynes  for  pain,  if  any  exists,  being  all  that  is  re- 
quired; later  in  the  case  hot  fomentations,  and  perhaps  strapping,  may  be 
necessary  to  stimulate  absorption.  Exceptionally  the  extravasation  con- 
tinues in  spite  of  preventive  measures,  in  which  event  the  tumor  may  be 
tapped  and  then  strapped  to  prevent  refilling;  if  this  is  not  successful,  hot 
water  with  a  little  iodin  in  solution  may  be  injected  through  the  trocar, 
and  will  usually  check  the  hemorrhage  as  well  as  effectually  prevent  sep- 
sis. Some  recent  authorities  recommend  primary  incision  under  antiseptic 
precautions  in  all  cases  of  hematocele.  The  author,  however,  is  inclined  to 
take  a  conservative  course,  unless  suppuration  or  firm  clotting  of  the  effu- 
sion occurs,  in  which  case  he  incises  freely,  secures  all  bleeding-points,  and 
applies  a  drainage-tube  with  full  antiseptic  dressings.  If  the  tunica  vagi- 
nalis is  markedly  thickened  it  should  be  dissected  away.     Hematocele  may 


HEMATOCELE    OF    THE    SPEEMATIC    COED.  927 

follow  operations  for  varicocele  and  requires  this  procedure;  this  has  heen 
the  author's  experience  on  several  occasions. 

When  the  walls  of  an  old  hematocele  are  thickened  or  calcareous  they 
should  be  dissected  out  and  the  cavity  allowed  to  heal  slowly  by  granula- 
tion, as  in  ordinary  cases.  In  cutting  into  an  hematocele  the  testicle  may 
be  split  if  great  care  is  not  observed;  this  accident  has  happened  to  ex- 
cellent operators,  and  may  be  avoided  by  passing  a  director  into  the  sac 
above  or  below  and  slitting  the  walls  upon  it. 

The  dangers  of  operated  hematocele  are  erysipelas,  gangrene,  and  sep- 
temia,  violent  reaction  being  quite  common  even  in  favorable  cases.  These 
dangers  may  be  avoided  in  some  chronic  cases  by  correcting  such  cachexias 
as  syphilis,  scurvy,  purpura,  and  general  systemic  depression. 

HEMATOCELE   OF  THE   SPEEMATIC   COED. 

Diffuse  hematocele  of  the  cord  has  been  described.  This  affection  is 
very  rare.  It  results  from  straining  at  stool,  lifting,  etc.,  and  may  com- 
plicate scrotal  hematocele. 

Treatment. — The  treatment  of  hematocele  of  the  cord  is  the  same 
as  that  of  the  ordinary  form;  indeed,  it  would  hardly  merit  attention  were 
it  not  for  its  resemblance  to  inguinal  hernia.  From  the  latter  disease  it 
may  be  differentiated  by  its  boggy  feel,  irreducibility,  the  absence  of  symp- 
toms of  strangulation,  and  the  subsidence  of  the  tumor  after  a  few  days' 
rest.  In  doubtful  cases  the  aspirator  or  exploratory  incision  will  clear  up 
the  diagnosis. 


CHAPTER  XL. 

Hydkocele, 

Htdeocele  is  one  of  the  most  frequent  chronic  diseases  of  the  testicle 
and  its  envelopes,  and  consequently  merits  careful  study.  It  consists  of 
an  accumulation  of  serous  fluid  within  the  cavity  of  the  tunica  vaginalis 
testis  or  within  a  cyst  in  connection  with  either  the  testicle  or  cord,  the 
former  being  what  is  termed  a  true,  or  simple,  hydrocele,  the  latter  an 
encysted  hydrocele,  or,  more  properly  speaking  perhaps,  a  cystic  tumor  of 
the  spermatic  cord  or  testicle. 

MoEBiD  Anatomy.  —  The  fluid  in  hydrocele  is  usually  highly  albu- 
minous, and  of  a  pale-yellow  or  straw  color,  its  chromatic  peculiarities  de- 
pending upon  the  presence  or  absence  of  hemoglobin  from  effused  blood  and 
the  quantity  of  the  latter.  In  cases  of  long  standing  the  fluid  may  contain 
fatty  and  granular  matter,  cholesterin,  epithelial  cells,  and,  if  inflammation 
has  occurred,  pus.  In  rare  cases  the  fluid  may  contain  spermatozoa — sper- 
matic hydrocele.  The  fluid  differs  from  that  of  general  dropsj^,  both  in  mode 
of  production  and  physical  properties.  It  sometimes  contains  spontaneously 
coagulable,  fibrinous  material  that  forms  a  laminated  deposit  on  exposure 
to  the  air,  and  in  some  cases  it  contains  as  great  a  proportion  of  salts  and 
albuminates  as  normal  lymph.  When  mixed  with  blood  it  is  highly  coag- 
ulable. This  fibrinous  material  sometimes  strongly  resembles  that  which 
forms  upon  the  inner  surface  of  the  pleura  in  pleuritic  effusion,  and  is 
deposited  in  a  manner  somewhat  similar  to  that  of  pleuritic  lymph.  It 
sometimes  forms  laminae  upon  the  inner  surface  of  the  tunica  vaginalis, 
which  become  partly  organized  and  are  sometimes  mixed  with  calcareous 
salts  to  such  a  degree  as  to  obscure  diagnosis. 

Etiology. — True  hydrocele  is  usually  the  result,  in  all  probability,  of 
long-continued  direct  irritation  of  the  tunica  vaginalis  from  mechanic  vio- 
lence or  irritation  produced  by  testicular  disease.  Sometimes  it  is  the  re- 
sult of  that  intangible  condition  known  as  "sympathetic  irritation,"  depend- 
ing upon  diseases  of  the  cord,  testicle,  or  urethra.  Slight  irritation,  of  long 
duration,  is  the  most  frequent  cause,  and  occupations  involving  movements 
that  rub  or  squeeze  the  testicle  favor  the  development  of  hydrocele.  It  is 
very  frequently  met  with  in  tropic  climates,  the  scrotum  being  relaxed  and 
pendulous,  thus  rendering  the  testes  more  liable  to  injury. 

The  explanation  of  the  formation  of  hydrocele,  or  rather  its  pathology, 
has  been  a  matter  of  much  doubt  and  discussion.  One  explanation  (and  a 
rather  flimsy  one)  that  has  been  suggested  is  that  hydrocele  is  due  to  "a 
loss  of  balance  between  secretion  and  absorption  by  the  tunica  vaginalis.'^ 
By  some  it  is  claimed  to  be  a  low  grade  of  inflammation,  and  this  is  probably 
the  correct  view.    The  author  holds  the  opinion  that  slight  injuries  are  often 

(928) 


ETIOLOGY    OF    HYDEOCELE. 


939 


received  at  one  time  or  another  during  the  life  of  the  individual  which  are 
considered  to  be  of  trifling  importance  and  are  speedily  forgotten,  yet  which 
nevertheless,  later  in  life,  produce  pathologic  changes  in  the  apparently 
healthy  organ.    Hydrocele  is  probably  often  produced  in  this  way. 

With  reference  to  the  frequency  of  hydrocele  in  tropic  climates,  it  is 
stated  that  in  Brazil  about  10  per  cent,  of  the  male  population  are  affected 
by  it. 

Hydrocele  sometimes  persists  after  the  subsidence  of  acute  inflamma- 
tion of  the  testicle,  and  in  cases  in  which  the  canal  of  the  tunica  vaginalis 
is  congenitally  patulous  so-called  congenital  hydrocele  results.  This  variety 
is  quite  infrequent. 


Fig.  211. — Vertical  section  of  simple  hydrocele. 
(After  Monod  and  Terrillon.) 


In  chronic  hydrocele  the  effusion  is  slow  and  painless  in  the  majority 
of  cases,  and  the  tumor  is  usually  discovered  by  accident,  unless  the  pa- 
tient is  in  the  habit  of  inspecting  his  genital  organs.  It  commences  at 
the  lower  part  of  the  testicle  in  front,  and  increases  from  below  upward; 
it  does  not  tend  to  subside  spontaneously,  but  to  indefinite  increase  of  fluid 
accumulation,  sometimes  of  an  enormous  amount.  The  quantity  of  fluid 
usually  varies  from  a  few  drams  to  a  pint,  but  may  reach  an  amount  of  from 
fifty  to  over  one  hundred  ounces.  Such  large  accumulations  give  great 
annoyance  from  their  bulk.  After  a  time  the  walls  of  the  hydrocele 
are  liable  to  undergo  fibrous  thickening,  or  even,  as  already  stated,  cal^ 
careous  or  cartilaginous  degeneration:    changes  that  greatly  obscure  the 


930  HTDKOCELE. 

diagnosis.  The  more  persistent  and  pronounced  tiie  irritation,  and  tlie 
more  frequent  the  injuries  to  which  the  testicle  is  subjected,  the  more 
likely  are  such  changes  to  occur  and  the  fluid  to  become  mixed  with  blood 
and  pus.  Secondary  cysts  may  form,  or  adhesions  may  occur  between  the 
serous  surfaces,  dividing  the  cavity  into  compartments;  rarely  the  pressure 
of  the  accumulated  fluid  causes  atrophy  of  the  testicle.  In  the  author's 
experience  the  testicle  has  been  usually  more  or  less  enlarged,  the  epididymis 
especially  being  hard,  the  enlargement,  however,  being  painless  and  not 
especially  tender  upon  pressure.  From  this  fact  it  would  appear  that  hydro- 
cele is,  in  the  majority  of  cases,  the  result  of  chronic  inflammation  of  the 
testicle  or  its  epididymis. 

Diagnosis. — The  diagnosis  of  the  disease  is  usually  simple.     Hydro- 


Fig.  212. — Double  hydrocele  of  tunica  A-aginalis.     (Author's  case.) 

cele  is  usually  pear-shaped,  its  larger  extremity  being  below,  but  it  may  be 
oval  or  even  spheric  if  very  large.  Fluctuation  is  usually  distinct;  and, 
although  the  tumor  is  tense  and  shining,  the  spermatic  cord  can  be  distin- 
guished above  it.  The  testicle  is  usually  situated  behind  the  effusion,  its 
peculiar  sensibility  being  manifest  on  pressure.  Sometimes,  however,  the 
organ  is  f oimd  below  or  in  front,  this  variation  in  position  being  dependent 
upon  plastic  adhesions.  Its  position  should  be  carefidly  determined  before 
any  operation  is  imdertaken,  as  injury  at  the  hands  of  the  surgeon  may 
prove  a  serious  matter.  Hydrocele  is  not  tender  on  pressure,  there  is  no 
heat  or  redness  of  the  scrotum  unless  tension  be  extreme,  and  there  is  usu- 
ally no  pain;  but  a  sensation  of  dragging  weight  on  the  cord  is  experienced 
in  the  majority  of  cases  in  which  the  eifusion  is  in  any  amount.  The  ef- 
fusion is  usually  easily  determined  by  viewing  the  upper  part  of  the  tumor 


TEEATMENT    OF    HYDEOCELE. 


931 


through  a  cylinder  of  some  sort,  a  lighted  candle  or  lamp  being  held  on  the 
opposite  side  of  the  tumor  and  the  room  being  darkened. 

Hydrocele  may  be  mistaken  for  hernia,  particularly  the  incarcerated 
form,  which  is  sometimes  complicated  by  more  or  less  serous  effusion.  Sim- 
ple hydrocele  may  be  complicated  by  simple  or  incarcerated  inguinal  hernia. 
Irreducibility  serves  to  differentiate  hydrocele  from  simple  hernia;  the  ab- 
sence of  pain  distinguishes  it  from  all  inflammatory  diseases;  its  smooth- 
ness of  surface  differentiates  it  from  cancerous,  tuberculous,  or  cystic  dis- 
ease;  and  its  translucency  from  syphilitic  affections. 

Teeatment. — The  cure  of  simple  hydrocele  in  young  subjects  is  some- 
times spontaneous — usually  so  in  acute  hydrocele.  We  may,  however,  resort 
to  operative  measures  of  tapping  or  acupuncture.     After  securing  strict 


Fig.  213. — Encysted  hydrocele  of  the  testis. 


asepsis,  the  first  step  in  the  operation  of  tapping  is  to  ascertain  the  position 
of  the  testicle.  The  tumor  is  made  tense  with  the  left  hand,  while  with 
the  right  a  fine,  well-oiled  trocar  is  plunged  into  its  anterior  surface  in  an 
upward  direction;  the  trocar  is  now  withdrawn,  and  the  cannula  moved 
about  freely  to  prevent  its  opening^s  impinging  upon  the  walls  of  the  sac. 
The  tumor  is  obliterated  by  the  escape  of  its  contents,  but  will  usually  re- 
fill in  from  a  few  days  or  a  week  to  several  months.  In  some  cases,  notably 
in  young  subjects  with  recent  hydrocele,  a  permanent  cure  results.  This  is 
not  to  be  expected  in  the  chronic  form.  If  the  subject  be  old  or  debilitated, 
or  the  hydrocele  large,  rest  for  a  few  days  should  be  enjoined,  and  the  whole 
of  the  fluid  should  not  be  withdrawn  at  one  sitting,  as  there  is  danger  of 
excessive  reaction,  sloughing,  and  even  death.  If  the  testicle  is  wounded, 
great  pain  will  be  experienced,  and  after  the  serum  has  been  withdrawn  a 


932  HYDKOCELE. 

flow  of  blood  will  follow.     In  such  cases  strapping  is  necessary  to  prevent 
further  effusion  of  blood  and  the  formation  of  hematocele. 

The  method  of  acnpuncture  consists  in  making  the  tumor  tense,  then 
puncturing  the  sac  repeatedly  with  a  needle,  rotating  it  as  it  is  being  with- 
drawn. In  the  course  of  twenty-four  to  forty-eight  hours  all  of  the  serum 
will  have  transuded  into  the  cellular  tissue  of  the  scrotum,  whence  it  is 
gradually  absorbed.  All  that  is  necessary  after  tapping  or  acupuncture  is  to 
apply  a  suspensory  bandage,  excepting  in  old  or  weakly  patients,  in  whom, 
as  we  have  seen,  rest  is  essential  for  a  few  days.  When  simple  tapping  or 
acupuncture  fails  in  a  child,  external  manipulation,  or  stimulation  of  the 
skin  of  the  scrotum  by  equal  parts  of  tincture  of  iodin  and  water,  or  almost 
any  stimulating  ointment  or  lotion,  may  be  successful  in  preventing  recur- 


Fig.  214. — Tapping  a  hydrocele. 

rence  of  the  effusion.  The  compound  iodin  ointment  is  especially  service- 
able in  such  cases.  In  the  adult,  however,  such  measures  are  a  mere  waste 
of  time..  Hydrocele  is  sometimes  cured  by  accidental  rupture,  but  it  has 
been  known  to  refill  even  after  such  an  accident. 

Many  measures  have  been  resorted  to  for  the  radical  cure  of  hydro- 
cele,' but  there  are  only  two  that  are  of  any  practical  importance,  and 
they  are  undoubtedly  the  best  means  of  treatment.  These  are  (1)  tapping 
and  injection  and  (2)  antiseptic  incision  or  excision.  Galvanopuncture  and 
electrolysis  have  not  been  given  a  fair  trial,  and  may  possibly  at  some  future 
time  be  demonstrated  to  be  a  reliable  method  of  treatment.  The  preferable 
method  is  injection  after  withdrawal  of  the  fluid.  All  simple,  translucent 
hydroceles  are  amenable  to  cure  by  injection,  but  it  is  not  applicable  where 
the  fluid  is  sero-purulent  or  sero-sanguinolent,  for  in  such  cases  adhesion 


TEEATMENT    OF    HYDEOCELE.  933 

fails  to  take  place,  and  treatment  by  antiseptic  excision  or  incision  of  the 
sac  becomes  necessary. 

The  flnids  that  have  been  used  in  injecting  the  sac  are  varions,  and 
among  them  may  be  mentioned  iodin,  port-Avine,  solutions  of  alum,  sulphate 
of  zinc,  lime-water,  carbolic  acid,  and  many  other  substances.  Of  these,  the 
tincture  of  iodin  has  been  most  generally  used,  although  carbolic  acid  has 
recently  been  demonstrated  to  be  by  far  the  best,  it  having  the  great  advan- 
tage of  comparative  painlessness,  on  account  of  its  anesthetic  properties. 
Of  all  substances  for  injection,  it  is  the  one  to  which  preference  should  be 
given.  The  author,  however,  has  attained  success  in  several  instances  by 
the  injection  of  quercus  alba  and  alcohol,  after  the  method  recommended  by 
Heaton  for  the  cure  of  hernia.  If  a  mild  injection  be  required,  the  com- 
pound tincture  of  iodin  diluted  with  water  may  be  used,  but,  if  necessary 
to  use  a  strong  injection,  the  pure  ordinary  or  compound  tincture  is  re- 
quired. It  is  often  well  to  precede  the  injection  by  palliative  tapping  and 
pressure  to  diminish  the  extent  of  the  absorbing  surface  prior  to  the  more 
radical  operation,  and  also  to  determine  whether  tapping  alone  is  likely  to 
effect  a  permanent  cure,  and  thus  render  injection  unnecessary.  Having 
evacuated  the  fluid,  the  sac  should  be  injected  with  50-per-cent.  solution  of 
carbolic  acid.  Before  doing  so,  however,  the  testicle  should  be  carefully 
examined,  as  it  is  now  accessible  to  the  touch.  If  there  is  no  more  serious 
condition  present  than  a  slight  hardening  and  thickening  of  the  epididymis, 
Ave  are  Avarranted  in  proceeding  Avith  the  operation.  The  amount  of  fluid, 
to  be  injected  should  correspond  to  about  one-half  the  fluid  withdraAvn. 
This  quantity  of  the  carbolic-acid  solution  should  be  slowly  injected  through 
the  cannula;  the  surgeon  then  stops  the  outer  opening  of  the  cannula  and 
manipulates  the  sac  so  as  to  bring  the  fluid  in  contact  Avith  every  portion  of 
its  surface;  after  alloAving  the  fluid  to  remain  in  the  sac  for  two  or  three 
minutes  it  is  permitted  to  escape.  The  patient  may  become  pale  under  the 
operation,  and  complain  of  faintness  and  nausea,  Avhich  perhaps  may  be  fol- 
loAved  by  vomiting  and  some  pain,  these  nervous  symjotoms  being  due  to 
slight  shock. 

In  performing  this  operation  care  should  be  taken  to  have  the  cannula 
well  within  the  cavity  of  the  hydrocele  before  throAving  in  the  injection  fluid, 
for  if  the  injection  should  enter  the  cellular  tissue  of  the  scrotum  serious 
sloughing  may  ensue.  The  patient  should  wear  a  suspensory  bandage,  and 
when  reaction  comes  on,  if  pain  is  excessive,  should  rest  in  bed.  This  he 
will  probably  be  compelled  to  do  at  the  end  of  twenty-four  to  thirty-six 
hours,  if  the  operation  be  successful.  Where  the  reaction  is  excessive,  it  is 
sometimes  necessary  to  apply  hot  poultices  and  administer  morphia  for  a 
fcAV  days.  If  the  reaction  be  insufficient,  manipulation  of  the  testicle  with 
the  hands  may  succeed  in  prgducing  a  suffieient  amount  of  inflammation 
to  effect  a  cure.  The  cure  is  usually  complete  at  the  end  of  from  three  to 
six  weeks,  a  second  operation  being  rarely  necessary.    If,  however,  the  in- 


934  HYDKOCELE. 

fiammatory  effusion  consequent  upon  the  injection  be  very  great,  it  may  be 
drawn  off  with  an  aspirator  or  trocar. 

The  operation  of  antiseptic  incision  is  excellent  in  some  cases,  and  the 
author  has  frequently  performed  it  with  the  best  results.  It  should  always 
be  resorted  to  when  there  is  any  doubt  in  diagnosis,  when  injection  fails, 
when  the  walls  of  the  sac  are  thick  from  calcareous  deposits,  when  the  hydro- 
cele is  complicated  by  hematocele,  and  when  the  contents  of  the  sac  are  sero- 
purulent.  Should  severe  inflammation  result  as  a  consequence  of  injection, 
the  open  method  by  antiseptic  incision  may  become  necessary,  it  being  in- 
variably indicated  if  suppuration  occurs.  In  performing  this  operation  the 
sac  is  to  be  freely  incised  from  top  to  bottom,  and,  if  the  walls  are  thickened 
or  calcareous,  they  should  be  dissected  out,  after  which  full  antiseptic  dress- 
ings should  be  applied,  the  cavity  being  packed  with  carbolized  or  iodoform- 
ized  gauze,  thus  compelling  it  to  granulate  from  the  bottom.  The  dressings 
should  be  removed  and  reapplied  about  the  fifth  day,  and  as  frequently  there- 
after as  may  seem  necessary,  until  healing  is  complete. 

Weir  has  recently  recommended  a  modification  of  the  ordinary  opera- 
tion of  tapping  for  simple  hydrocele  that  seems  to  possess  considerable  merit. 
It  consists  in  tapping  the  sac  with  a  large  trocar  and  cannula,  after  which 
the  sac  is  washed  out  with  carbolic  acid,  1  to  15;  a  drainage-tube  is  now 
inserted  through  the  cannula,  the  latter  being  then  removed,  leaving  the 
tube  in  situ.  Full  antiseptic  dressings  are  next  applied,  and  the  parts 
allowed  to  remain  undisturbed  for  five  or  six  days,  when  the  dressing  is  re- 
applied. At  the  end  of  nine  or  ten  days  the  drainage-tube  is  removed,  and 
it  will  be  found  that  a  cure  has  been  effected  in  the  majority  of  cases. 

A  modification  of  the  antiseptic  incision  is  also  advocated  by  Volkmann 
After  the  cavity  has  been  irrigated  with  3-per-cent.  solution  of  carbolic  acid, 
fifteen  to  twenty  sutures  are  placed  in  the  cutaneous  and  serous  edges  of  the 
incision,  thus  uniting  the  tunica  vaginalis  to  the  skin.  Some  gaping  of  the 
wound  is  allowed,  with  a  certain  amount  of  exposure  of  the  testis.  Anti- 
septic dressings  are  applied  and  the  cavity  allowed  to  granulate. 

In  aged,  weak,  badly-nourished,  or  anemic  patients,  chronic  dropsy  of 
the  tunica  vaginalis  testis  sometimes  occurs,  being  associated  with  general 
hydremia.  In  such  cases  the  blood,  being  poor  in  plastic  materials,  is  prone 
to  exudates  and  effusions  of  various  kinds.  Other  and  more  serious  serous 
effusions  are  apt  to  co-exist  with  the  hydrocele,  the  latter,  therefore,  being 
of  secondary  importance.  The  primal  object  of  treatment  in  such  cases  is 
to  restore  the  general  health  and  improve  the  quantity  and  quality  of  the 
blood.  A  suspensory  bandage  should  be  worn,  and,  if  the  accumulation  of 
fluid  becomes  very  excessive,  relief  may  be  afforded  by  puncture  or  aspira- 
tion. After  the  general  health  has  been  restored,  a  radical  cure  may  be  at- 
tempted if  the  local  condition  has  not  already  subsided  pari  passu  with 
improvement  in  the  general  health.  Inflammatory  and  syphilitic  affections 
of  the  testes  are  frequently  attended  by  a  certiain  amount  of  effusion  into  the 


CONGENITAL    HTDEOCELE. 


935 


tunica  vaginalis,  which  usually  subsides  with  the  disappearance  of  its  or- 
ganic cause.  Acute  epididymitis  and  orchitis  are  accompanied  by  sero-plastic 
effusion,  constituting  what  is  known  as  acute  hydrocele,  the  treatment  of 
which  consists  in  the  proper  management  of  the  acute  inflammatory  affec- 
tion. 

The  rarer  forms  of  hydrocele  merit  special  consideration,  not  only  be- 
cause of  their  importance  per  se,  but  also  from  the  liability  to  diagnostic 
errors. 

Congenital  Htdeocele. — This  is  a  form  of  hydrocele  that  is  occa- 
sionally seen  which  differs  considerably  from  the  simple  variety  in  its  an- 
atomic characteristics.  Congenital  hydrocele  is  the  result  of  an  anatomic 
defect  in  the  region  involved.  When  the  testicle  descends  into  the  scrotum 
during  fetal  life,  it  is  accompanied  by  a  prolongation  of  the  peritoneum 


Fig.  215. — Hydrocele  complicated  by  hernia. 


lying  in  front  of  it.  This  prolongation  of  peritoneum  should  normally  be- 
come obliterated  at  its  neck,  forming  a  firm  fibrous  cord  termed  the  hahenula 
of  Scarpa.  The  portion  below  it  remains  unobliterated,  and  invests  the 
testis  by  a  double  layer,  forming  the  tunica  vaginalis  testis.  The  testicle 
does  not  lie  within  this  cavity,  but  external  to  it,  the  relation  of  the  organ 
to  its  investment  being,  as  already  remarked,  precisely  similar  to  the  rela- 
tion which  the  lung  and  pleura  bear  to  each  other.  When  the  neck  of  this 
serous  sac  remains  open,  the  abdominal  walls  must  necessarily  be  defective 
at  the  internal  abdominal  ring,  as  a  consequence  of  which  there  is  a  predis- 
position to  hernia — congenital  inguinal  hernia — and  to  gravitation  of  the 
serum  secreted  in  the  abdominal  cavity  into  the  bottom  of  the  serous  sac 
constituting  the  tunica  vaginalis  testis,  thus  forming  congenital  hydrocele. 
From  the  peculiar  anatomic  condition  prevailing  in  congenital  hydrocele, 
it  is  obvious  that  the  disease  is  quite  apt  to  be  complicated  by  congenital 


936  HYDROCELE. 

hernia.  Hernia  and  hydrocele  may  also  co-exist  at  any  period  of  life  in- 
dependently of  congenital  patulonsness  of  the  prolongation  of  peritoneum 
to  which  the  testis  is  attached. 

Diagnosis. — The  diagnosis  of  congenital  hydrocele  is  usually  easy.  It 
may,  however,  be  confounded  with  hernia.  It  is  rare  in  adults,  and  can 
usually  be  readily  determined  in  children  by  the  same  methods  of  examina- 
tion as  in  simple  hydrocele.  It  will  be  found,  however,  that  the  fluid  con- 
tained in  the  hydrocele  is  readily  reducible  into  the  abdomen.  This  feature, 
the  age  of  the  patient,  and  the  absence  of  solid  contents  in  the  sac  consti- 
tute the  chief  characteristics  determining  the  diagnosis  of  congenital  hydro- 
cele. If  omentum  or  intestine  is  also  present  in  the  sac,  constituting  a  com- 
plicating congenital  hernia,  the  condition  is  usually  quite  readily  determined 
by  palpation  and  by  the  peculiar  gurgling  sound  attendant  upon  reduction 
of  the  mass  into  the  abdominal  cavity. 

Treatment. — The  treatment  of  congenital  hydrocele  should  be  conserva- 
tive, being  based  upon  the  same  principles  as  those  of  the  treatment  of  hernia 
in  young  subjects.  As  a  rule,  the  disease  is  readily  cured  by  the  application 
of  a  well-fitting  truss,  the  object  to  be  accomplished  being  obliteration  of 
the  neck  of  the  sac.  The  fluid  is  usually  reabsorbed  quite  promptly,  a  cure 
being  complete  in  from  two  to  eight  months.  This  mechanic  process  of 
obliteration  is  as  near  as  may  be  an  accurate  imitation  of  Nature's  own 
method  of  cure.  Congenital  hydrocele  should  never  be  injected,  as  such 
a  procedure  would  be  nothing  more  nor  less  than  the  application  of  irritating 
materials  to  the  general  cavity  of  the  peritoneum,  the  serous  surfaces  of  the 
cavity  of  the  tunica  vaginalis  and  that  of  the  general  peritoneal  cavity  being 
continuous;  fatal  peritonitis  would  therefore  be  apt  to  result  should  we  at- 
tempt to  operate  upon  congenital  hydrocele  as  in  the  simple  form  of  the 
disease.  Where  simple  pressure  is  not  successful,  the  sac  should  be  dissected 
out  and  removed  as  high  up  as  possible,  the  disposition  of  the  sac  being  simi- 
lar to  that  employed  in  the  radical  cvire  of  hernia. 

Hernia  of  the  ordinary  variety  is  sometimes  complicated  by  a  spurious 
form  of  hydrocele.  This  is  usually  brought  about  by  the  occlusion  of  the 
neck  of  an  old  hernial  sac,  by  the  pressure  of  a  truss,  or  by  a  bit  of  intestine 
or  omentum,  which  blocks  it  up,  after  which  the  sac  fills  with  fluid,  con- 
stituting hydrocele  of  the  hernial  sac.  It  should  be  remembered  that  in  this 
condition  the  fluid  is  not  in  the  cavity  of  the  tunica  vaginalis  testis,  but  in 
the  hernial  sac:  a  special  pouch  of  peritoneum  brought  down  by  the  intes- 
tine in  its  fetal  descent. 

The  history  of  the  case  must  be  our  guide  to  its  diagnosis  and  treat- 
ment. Injection  is  contra-indicated,  antiseptic  incision  being  the  proper 
procedure.  After  the  incision  is  made  and  the  fluid  evacuated,  any  portion 
of  omentum  or  intestine  present  in  the  neck  of  the  sac  must  be  reduced  and 
the  sac  removed,  after  which  the  usual  radical  operation  for  hernia  should 
be  performed  and  antiseptic  dressings  applied.     The  accumulation  of  fluid 


SPEEMATOCELE.  937 

about  an  incarcerated  hernia  is  also  a  sjDurious  form  of  h3^clrocele.  The  fluid 
in  all  forms  of  hydrocele  complicating-  hernia,  or,  more  properly  speaking, 
dropsy  of  the  hernial  sac,  is  usually  of  a  dark  color. 

Speematocele. — This  is  a  variety  of  hydrocele  consisting  of  a  collec- 
tion of  serous  fluid  containing  spermatic  elements,  either  in  the  tunica 
vaginalis  testis  or,  as  is  most  usually  the  case,  in  a  cyst  in  the  vicinity  of  the 
epididymis.  The  term  spermatocele  has  been  erroneously  applied  by  some 
authorities  to  a  condition  more  accurately  defined  as  spermatic  congestion. 
This  is  a  result  of  prolonged  and  ungratitied  sexual  excitement,  which  causes 
the  testes  to  become  hard,  enlarged,  knotty  to  the  feel,  and  hot  and  tender 
to  the  touch.  The  entire  spermatic  cord  becomes  tense  and  tender  and  the 
scrotum  red  and  swollen,  the  aggregate  symptoms  being,  in  brief,  those  of 
impending  inflammation  of  the  testis.  Nature  sometimes  comes  to  the  rescue 
in  cases  of  this  kind,  and  an  involuntary  emission  relieves  the  congestion  of 
the  vesiculce  seminales  and  tubuli  sem,iniferi.  In  lieu  of  the  natural  means 
of  relief,  perfect  rest,  particularly  as  regards  sexuality  of  thought,  and  the 
application  of  cooling  lotions  are  indicated. 

True  spermatocele  is  a  cystic  growth  connected,  as  a  rule,  with  the  epi- 
didymis, and  containing  spermatozoa.  The  presence  of  spermatozoa  in  the 
cavity  of  the  tunica  vaginalis  is  always  due  to  the  rupture  of  a  spermatocele, 
and  is  a  possible  complication  of  simple  hydrocele.  Explanatory  of  the 
formation  of  true  spermatocele  a  brief  description  of  the  fetal  development 
of  the  testicle  is  essential. 

The  testicle  is  developed  in  the  fetus  in  the  vicinity  of  the  Wolffian 
body,  but  independently  of  this  structure  so  far  as  the  body  of  the  testis  is 
concerned.  The  Wolffian  body  is  composed  of  a  series  of  tubuli  opening 
into  what  is  known  as  the  duct  of  the  Wolffian  body,  and  this  in  turn  empties 
into  the  uro-genital  canal.  This  Wolffian  duct  in  the  female  becomes  ob- 
literated, but  in  the  male  becomes  the  vas  deferens.  The  central  tubes  of 
the  Wolffian  body  are  connected  by  their  open  extremities  with  the  testes 
and  subsequently  form  the  structure  known  as  the  coni  vasculosi,  connecting 
the  testes  with  the  canal  or  duct  of  the  epididymis.  One  or  more  of  the  lower 
tubes  of  the  Wolffian  body  eventually  constitute  what  is  termed  by  Haller 
the  vasculum  alerrans.  Some  of  the  upper  tubes  atrophy,  while  others  form 
the  so-called  non-pediculated  hydatids  or  little  simple  cysts  that  exist  in  con- 
nection with  the  epididymis.  From  one  of  these  so-called  non-pediculated 
hydatids  spermatocele  is  probably  formed.  Another  remnant  of  the  Wolffian 
body  is  termed  the  corpus  innominatum  of  Giraldes.  This  consists  of  a  con- 
volution of  tubes  with  cecal  or  blind  extremities.  In  the  female  the  tubuli 
of  the  Wolffian  body  continue  cecal  throughout,  forming  what  is  termed  by 
Eosenmiiller  the  parovarium,  which  furnishes  the  little  cysts  that  are  nor- 
mally found  in  the  external  border  of  the  broad  ligament.  It  is  an  excessive 
development  of  one  or  more  of  these  cysts  which  later  in  life  forms  the  patho- 
logic parovarian  or  intraligamentous  cyst,  so  apt  to  be  mistaken  for  simple 


938  HYDROCELE. 

ovarian  cyst.  It  will  be  observed,  therefore,  that  the  correlation  of  spermat- 
ocele and  cyst  of  the  broad  ligament  is  by  no  means  paradoxic. 

There  is  another  fetal  structure  that  is  important  in  considering  the 
development  of  the  testicle :  the  duct  of  Miiller.  This  is  a  tube-like  structure 
that  commences  in  a  closed  or  cecal  extremity  and  traverses  the  Wolffian 
body,  without  being  organically  connected  with  the  latter,  and  empties  by 
a  separate  opening  in  the  vicinity  of  the  Wolffian  duct  in  the  uro-genital 
canal.  This  atrophies  in  the  male  subject,  but  its  blind  extremity  sometimes 
persists,  constituting  what  is  termed  the  hydatid  of  Morgagni:  a  pediculated 
cyst  at  the  head  of  the  epididymis.  Its  other  extremity  eventually  consti- 
tutes the  utriculus  prostaticus,  or  sinus  pocularis,  supposed  to  be  the  homo- 
logue  of  the  uterus.  In  the  female  the  open  extremity  of  the  duct  of  Miiller 
becomes  fimbriated,  forming  the  outer  extremity  of  the  Fallopian  tube.  It 
will  be  readily  seen  that  a  cyst  of  a  remnant  of  the  duct  of  Miiller  could  not 
become  a  spermatocele,  as  the  duct  was  never  connected  with  the  Wolffian 
body,  while,  upon  the  other  hand,  it  is  quite  as  plain  that  the  connection 
between  the  tubes  of  the  Wolffian  body  and  the  duct  of  the  Wolffian  body 
(now  the  canal  of  the  epididymis  and  vas  deferens)  might  readily  be  reopened 
or  even  remain  in  its  patulous  fetal  condition,  forming  a  cyst  that  is  readily 
entered  by  true  spermatic  elements.  It  has  been  supposed  that  some  of  the 
tubuli  seminiferi  themselves  might  develop  into  cysts,  but  this  has  never 
been  satisfactorily  demonstrated. 

Spermatocele  tends  to  increase  in  size  indefinitely,  and,  as  we  have  seen, 
may  co-exist  with  or  finally  rupture  into  the  sac  of  a  hydrocele,  forming 
in  this  manner  the  so-called  spermatic  hydrocele.  When  complicated  in  this 
manner  spermatocele  cannot  be  clearly  distinguished,  but  when  existing 
alone  it  presents  itself  in  the  form  of  a  slowly-growing  tumor,  elastic  and 
possibly  fluctuating  to  the  feel,  in  connection  with  the  epididymis.  It  is 
generally  somewhat  translucent  by  transmitted  light.  The  patient  is  often 
hypochondriac  in  cases  of  this  kind  and  imagines  that  his  sexual  powers  are 
failing  or  that  he  is  absolutely  impotent.  There  is  little  or  no  pain,  as  a  rule, 
but  a  slight  dragging  sensation  is  experienced  along  the  cord.  In  excep- 
tional cases  neuralgia  of  the  testicle  may  exist  as  a  complication.  When  fully 
developed  the  tumor  has  been  described  as  somewhat  pear-shaped. 

Diagnosis. — The  diagnosis  is  to  be  determined  by  the  characters  of  the 
fluid,  which  is  usually  milky  and  always  contains  spermatozoa. 

Treatment. — The  cyst  alwaj^s  refills  after  tapping,  incision  or  injection 
- — as  recommended  for  simple  hydrocele — ^being  necessary  to  complete  the 
cure.  The  author's  preference  in  cases  of  this  kind  is  for  antiseptic  incision, 
with  or  without  excision  of  the  sac. 

Hydeocele  of  the  Spermatic  Cord. — This  affection  is  not  frequently 
met  with.     The  effusion  may  be  either  infiltrated  and  diffuse  or  encysted. 

Diffuse  Form. — The  spermatic  cord  is  invested  with  a  sheath  of  areolar 
tissue  derived  from  the  perimysium  of  the  abdominal  muscles.    This  invest- 


HYDROCELE    OF   THE    SPEEMATIC    CORD. 


939 


ment  begins  at  the  external  abdominal  ring  and  invests  the  cord  throughout 
its  whole  extent,  becoming  eventually  attached  to  the  testicle.  This  is  by 
some  described  as  a  separate  fascia  known  as  the  tunica  vaginalis  communis. 
The  meshes  of  this  fascia  sometimes  become  the  seat  of  serous  infiltration, 
constituting  a  diffuse  form  of  hydrocele  of  the  cord.  This  condition  is  very 
rare  indeed;  even  its  existence  is  denied  by  some  very  eminent  authorities. 
Curling  described  such  an  affection  and  ascribed  it  to  acute  orchitis  and  to 
general  anasarca.  True  hydrocele  of  the  cord  is  sometimes  produced  by  en- 
larged inguinal  glands  or  other  sources  of  mechanic  obstruction  to  the  re- 
turn of  blood  from  the  testicle.  It  is  mainly  important  from  its  liability  to 
be  mistaken  for  omental  hernia  and  vice  versa.  There  is  no  difficulty  in 
distinguishing  it  from  ordinary  hydrocele.  The  tumor  is  uniform,  round, 
and  smooth  in  the  majority  of  cases,  and  toward  its  base,  where  it  is  largest, 
it  sometimes  contains  one  large  cavity.     It  ceases  abruptly  at  the  testicle 


Fig.  216. — Encysted  hydrocele  of  cord.     (After  Bryant.) 


below,  that  organ  being  plainly  distinguishable  from  it,  and  when  the  pa- 
tient is  in  a  supine  position  it  diminishes  somewhat  in  size  and  becomes  more 
cylindrical,  but  does  not  disappear.  It  is  not  completely  reducible  and  will 
return  in  any  position  of  the  patient,  thus  distinguishing  it  from  reducible 
omental  hernia.  When,  however,  omental  hernia  is  irreducible  the  diag- 
nosis is  more  difficult,  and  often  impossible  without  exploratory  incision. 

Treatment. — The  proper  treatment  consists  of  puncture,  and,  if  this 
fails,  antiseptic  incision. 

Encysted  Form,. — This  variety  may  occur  in  the  connective-tissue  sheath 
of  the  cord  or  in  portions  of  the  hdbenula  of  Scarpa,  the  peritoneal  prolonga- 
tion forming  the  neck  of  the  tunica  vaginalis,  which  have  not  become  oc- 
cluded. These  cysts  vary  in  size  from  that  of  a  pea  to  a  hen's  egg;  are  tense, 
smooth,  of  oval  form,  and  not  painful  or  tender  to  the  touch,  or,  at  least, 
very  slightly  so.  Fluctuation  is  not  usually  perceptible  on  account  of  the 
extreme  tension  of  the  cyst-walls.    These  cysts  are  generally  found  between 


940  HTDEOCELE. 

tlie  external  ring  and  testicle,  but  may  occnr  in  the  inguinal  canal.  Their 
long  diameter  is  parallel  with  the  cord,  and  when  located  in  the  inguinal 
canal  they  are  usually  mistaken  for  inguinal  hernia,  and  a  truss  applied. 
This  treatment,  however,  aggravates  the  trouble,  causing  pain  and  soreness. 
An  exploratory  incision  may  be  necessary  to  an  accurate  diagnosis,  and  under 
our  modern  methods  of  antisepsis  is  indicated  in  all  obscure  cases.  It  should 
be  a  preliminary  to  dissecting  out  the  sac. 

Treatment. — In  the  treatment  of  large  encysted  hydrocele  of  the  cord 
the  same  measures  should  be  adopted  as  in  simple  hydrocele.  If,  however, 
there  are  several  communicating  cysts,  injection  is  likely  to  fail  and  incision 
or  excision  will  be  necessary.  A  cutting  operation  is  always  demanded  for 
cysts  in  the  inguinal  canal  or  when  there  is  the  slightest  doubt  as  to  the 
presence  of  hernia.  Incision  or  the  introduction  of  small  setons  will  obliter- 
ate any  small  cysts  that  may  exist  external  to  the  inguinal  ring.  In  a  recent 
case  of  the  author's  a  cure  was  effected  by  injecting  a  few  drops  of  carbolic 
acid  into  the  cyst  with  the  hypodermic  syringe. 


CHAPTEE  XLI. 
INFLAMMATORY  AFFECTIONS  OF  THE  TESTIS. 

Epididymitis  and  Oechitis. 

Acute  and  chronic  inflammatory  processes  affecting  the  testis  are  met 
with  in  two  separate  and  distinct  forms,  viz.:  inflammation  of  the  epidid- 
ymis and  inflammation  limited  more  or  less  completely  to  the  body  of  the 
organ.  Inflammation  of  the  epididymis  is  the  most  frequent  of  all  forms  of 
testicular  disease.  The  limitation  of  the  inflammation  to  the  portion  of  the 
testicle  primarily  affected  is  explicable  chiefly  by  the  fact  that  the  arterial 
supply  of  each  structure  is,  to  a  certain  degree,  separate  and  distinct.  It  is 
probable,  also,  that  the  tissues  of  the  epididymis  react  more  readily  to  causes 
of  irritation  than  the  body  of  the  testis  proper.  Inflammation  of  the  epidid- 
ymis, however,  is  more  apt  to  extend  to  the  body  of  the  organ  than  primary 
inflammation  of  the  latter  to  the  epididymis.  Epididymitis  is  always  at- 
tended by  more  or  less  inflammation  of  the  tunica  vaginalis  testis — peri- 
orchitis, or  acute  hydrocele,  while  in  orchitis  the  inflammation  is  generally 
limited  by  the  dense  and  resisting  tunica  albuginea.  When  the  testis  in- 
flames as  a  result  of  injury,  both  portions  of  the  organ  are  likely  to  be 
affected  simultaneously.  It  is  doubtful  if  gonorrheal  epididymitis  ever  in- 
volves the  body  of  the  testis  to  any  great  degree,  for,  inasmuch  as  this  par- 
ticular complication  of  gonorrhea  is  exceedingly  frequent,  one  would  antici- 
pate a  greater  number  of  unfavorable  results,  if  the  inflammation  often 
involved  the  secreting  structure  of  the  testis,  true  orchitis  being  a  very  serious 
matter.  Gonorrheal  inflammation  of  the  organ  terminates  favorably,  as  a 
rule,  and  if  orchitis  were  a  prominent  element  the  disease  would  be  much 
more  severe  than  it  ordinarily  is.  Co-existing  epididymitis  would  not  render 
the  inflammation  of  the  body  of  the  testis  less  serious,  but  would  undoubt- 
edly enhance  its  dangers. 

ORCHITIS. 

Primary  inflammation  of  the  body  of  the  testis  is  uncommon,  and,  as 
already  indicated,  orchitis  secondary  to  inflammation  of  the  epididymis  is 
probably  rarer  still. 

Etiology. — The  most  frequent  cause  of  orchitis  is  the  general  infec- 
tion of  parotitis,  or  mumps.  It  occurs  in  about  5  per  cent,  of  cases  of  young 
male  subjects  affected  with  this  disease.  This  form  of  orchitis  has  been 
termed  "metastatic":  a  term  which,  in  the  light  of  modern  surgical  pa- 
thology, is  very  unscientific  and  unsatisfactory.  It  is  probable  that  the  spe- 
cific infection  of  parotitis  has  a  predilection,  not  only  for  the  parotid  gland, 
but  for  the  testis.    Fortunately,  the  disease  expends  its  violence  upon  the 

(941) 


942  INFLAMMATOKY   AFFECTIONS    OF    THE    TESTIS. 

parotid  gland  in  the  majority  of  cases — the  testis  thereby  escaping  infection; 
in  others,  however,  from  some  unknown  cause,  probably  inherent  to  the  in- 
dividual constitution,  the  testis  is  attacked  secondarily;  in  still  others,  it  is 
affected  primarily,  the  parotid  gland  escaping  entirely. 

The  subjects  most  liable  to  orchitis  are  those  just  approaching  adoles- 
cence, in  whom  the  sexual  organs  are  especially  active,  while  the  testis  is 
extremely  sensitive.  Involvement  of  the  epididymis  is  exceptional.  As  a 
rule,  but  one  organ  is  affected,  but  the  inflammation  may  suddenly  attack 
the  other;  it  has  been  known  to  attack  the  remaining  testis  after  the  parotitis 
itself  has  disappeared.  The  inflammation  usually  develops  from  four  to  ten 
days  after  the  inception  of  mumps.  Orchitis  is  sometimes  precipitated 
by  slight  injury,  the  stimulation  incident  to  masturbation  or  sexual  excite- 
ment (particularly  if  the  latter  be  ungratified),  or  by  exposure  to  cold  and 
wet  while  parotitis  is  at  its  height.  In  the  female  the  ovary  is  sometimes 
affected. 

Orchitis  lasts  from  four  days  to  two  weeks,  and  usually  terminates  favor- 
ably. In  exceptional  instances  abscess  occurs  from  secondary  mixed  infec- 
tion, and,  in  still  rarer  instances,  gangrene.  Atrophy  of  the  testis,  begin- 
ning at  a  variable  period  after  the  inflammation  subsides  and  resulting  in 
complete  destruction  of  the  organ,  is  more  frequent  than  suppuration  or 
gangrene. 

Orchitis  is  occasionally  due  to  injury  of  the  testis,  this  form  being  per- 
haps next  in  frequency  to  that  just  described.  Abscess,  gangrene,  atrophy, 
and,  in  rare  instances,  chronic  induration  of  the  organ  are  possible  results  of 
traumatic  orchitis,  especially  if  infection  be  superadded. 

Other  infectious  constitutional  diseases  besides  mumps  have  been  known 
to  be  complicated  by  orchitis.  Measles,  variola,  and  typhoid  fever  have  been 
known  to  cause  it.  Idiopathic  orchitis,  or,  at  least,  a  form  in  which  no 
definite  cause  can  be  ascertained,  has  been  described.  Such  cases,  how- 
ever, are  in  all  probability  due  to  infection  with  the  specific  poison  of 
mumps  where  parotid  involvement  is  skipped.  Inordinate  sexual  excitement 
has  been  said  to  produce  orchitis,  but  this  cause  is  probably  inefficient  in 
the  absence  of  some  predisposing  condition,  such  as  mumps,  injury,  or  gon- 
orrhea.    Gonorrhea,  however,  rarely  produces  true  orchitis. 

Orchitis  of  a  rheumatic  type  has  been  described.  Keyes  has  described 
such  cases.  A  number  of  cases  relatively  of  an  apparently  rheumatic  char- 
acter have  occurred  in  the  author's  practice. 

Gout  is  said  to  attack  the  fibrous  structures  of  the  testicle  in  the  form 
of  subacute  or  chronic  inflammatory  thickening.  The  author  has  not,  how- 
ever, met  with  any  cases  of  this  kind.  Cases  are  related  where  true  orchitis 
has  occurred  spontaneously  in  patients  with  chronic  urethral  and  prostatic 
disease.  Such  cases  were  formerly  considered  remarkable,  but,  in  the  light 
of  our  present  information  on  the  subject  of  genito-urinary  infection,  are 
hardly  worthy  of  special  comment.     The  spontaneity  of  development  in 


SYMPTOMS    OF    ORCHITIS.  943 

these  cases  is  only  apparent,  not  real.  Tliey  are  attributable  to  injury  pro- 
duced by  attempts  at  catheterization,  or  to  absorption  of  the  infectious 
products  of  chronic  vesical  and  prostatic  inflammation.  The  resulting  in- 
fection excites  an  inflammation  that  traverses  the  vas  deferens  and  finally 
involves  the  secreting  structure  of  the  testis.  It  is  possible  that  in  some  of 
these  cases  the  testicular  infection  occurs  in  a  roundabout  fashion  via  the 
general  circulation.  In  most  cases  of  orchitis  some  direct  exciting  or  re- 
mote predisposing  cause  can  be  detected  by  careful  study  of  the  history  of 
the  case. 

Orchitis  of  a  more  or  less  severe  type  is  sometimes  associated  with 
spermatic  phlebitis  due  to  secondary  infection  in  grip.  The  author  has  met 
with  a  case  of  this  kind. 

Symptoms. — The  symptoms  of  orchitis  are  much  more  severe  than 
those  of  epididymitis,  and  entirely  disproportionate  to  the  extent  of  the  in- 
flammation. This  is  readily  explicable  by  the  highly  sensitive  nervous  sup- 
ply and  peculiar  anatomic  structure  of  the  testis.  The  tunica  albuginea  is 
very  dense  and  resisting,  and  yields  but  little  to  the  pressure  of  inflamma- 
tory exudate  in  and  about  the  tubuli  seminiferi.  Any  apparent  enlarge- 
ment of  the  organ  in  true  orchitis  is  due  rather  to  an  inflammatory  thicken- 
ing of  the  tunica  albuginea  than  to  yielding  of  that  structure  under  the 
pressure  of  its  contents.  The  testis  being  abundantly  supplied  with  sympa- 
thetic nerve-filaments,  intense  depression  is  produced  by  inflammation  of  the 
organ.  In  addition  to  the  symptoms  of  local  inflammation,  we  have  phe- 
nomena characteristic  of  strangulation  of  tissue  in  any  situation.  Thus, 
nausea  and  vomiting,  a  pinched  appearance  of  the  features,  and  a  cold, 
moist  skin  with  severe  prostration  may  be  present,  just  as  in  strangulated 
hernia,x  constriction  of  the  bowels,  or,  indeed,  any  affection  in  which  sensi- 
tive tissues  are  closely  constricted  by  unyielding  contiguous  structures.  The 
pain  is  somewhat  similar  to  that  produced  by  biliary  or  nephritic  calculus. 
In  the  course  of  the  inflammation  painful  reflex  spasms  of  the  cremaster 
muscle  occur.  In  some  cases  fever  may  succeed  the  primary  depression. 
The  pain  is  very  severe  for  some  hours,  or  perhaps  several  days,  and  then 
gradually  subsides.  The  subsidence  of  pain  is  sometimes  an  indication  of 
the  occurrence  of  gangrene,  the  patient  meanwhile  flattering  himself  that 
he  is  in  a  fair  way  to  recover.     This  should  be  borne  in  mind. 

The  inflamed  organ  is  smooth,  ovoid,  and  only  moderately  enlarged, 
unless  the  epididymis  be  involved,  in  which  case  it  may  attain  a  great  size, 
as  in  ordinary  epididymitis.  Suppuration  may  occur,  either  with  or  without 
gangrene.  Gangrene  is  usually  heralded  by  a  more  or  less  distinct  chill,  or 
perhaps  succession  of  chills.  After  a  time  the  swollen,  indurated,  and  ine- 
lastic organ  softens  at  some  particular  spot;  the  scrotum  becomes  adherent 
to  the  borders  of  the  softened  area,  and  flnally  ulcerates,  giving  exit  to  a 
small  quantity  of  usually  unhealthy-looking  pus.  If  the  testis  has  become 
gangrenous  meanwhile,  the  secreting  structure  soon  protrudes  from  the 


944  INFLAMMATOEY    AFFECTIONS    OF    THE    TESTIS. 

opening  in  the  scrotum  in  the  form  of  a  grayish  or  yellowish,  dry  soft  mass 
not  unlike  inspissated  pus.  This  may  be  pulled  away  in  long  stringy  masses, 
representing  the  tubuli  seminiferi.  Fungoid  granulations  may  form  at  the 
ulcerated  spot  and  grow  to  an  enormous  size — fungus  testis,  or  hernia  testis. 
The  secreting  structure  of  the  testis  may  gradually  protrude  until  it  is  en- 
tirely external  to  the  scrotum,  forming,  with  the  granulations,  a  fungoid, 
proliferating,  unhealthy-looking  mass.  In  such  cases  there  is  a  strong  re- 
semblance to  encephaloid  cancer — fungus  hematodes — particularly  if — as  is 
occasionally  the  case — the  lymphatic  glands  in  the  groins  react  and  become 
enlarged  and  tender. 

Due  attention  should  be  paid  to  the  history  of  the  case  if  mistakes  in 


Fig.  217. — Benign  fungus  of  testis.     (After  Pean.) 

diagnosis  would  be  avoided.  The  fungoid  mass  may  become  ver}^  vascular, 
minute  hemorrhages  occurring  from  time  to  time.  The  blood  drying  upon 
the  surface  of  the  unhealthy-looking  growth  increases  the  resemblance  to 
fungus  hematodes.  Small  abscesses  may  form  in  the  substance  of  the  testis 
and  very  gradually  work  their  way  to  the  surface.  There  may  consequently 
be  numerous  sinuses  permeating  the  organ  in  various  directions,  commu- 
nicating with  a  central  cavity  lined  with  a  j^us-producing  pseudomembrane 
that  shows  no  tendency  to  cicatrize.  These  cases- are  not  usually  curable  save 
by  complete  extirpation  of  the  organ,  although  in  a  few  instances  recovery 
has  resulted  from  destruction  of  the  lining  membrane  of  the  pus-cavity  by 


TEEATMENT    OF    OECHITIS.  945 

cauterization.  In  the  majority  of  instances  there  is  a  history  of  rejDeated 
unsuccessful  cauterizations  and  incisions.  Caseous  degeneration  or  even 
true  tubercular  disease  of  the  organ  may  occur  in  such  cases  and  produce 
serious  deterioration  of  the  patient's  health,  perhaps  leading  secondarily  to 
tuberculosis  of  other  organs. 

Teeatment. — The  treatment  of  acute  orchitis  should  be  vigorously 
antiphlogistic.  The  patient  should  be  put  to  bed  immediately,  and  should 
be  kept  upon  his  back  with  the  testicles  elevated  upon  a  pillow  until  the  in- 
flammation has  entirely  abated.  Leeches  should  be  applied  to  the  scrotum 
and  over  the  external  abdominal  ring.  Puncture  of  the  scrotal  veins  has 
been  suggested,  the  bleeding  being  encouraged  by  fomentations  with  warm 
water.  A  saline  or  mercurial  cathartic  should  be  given,  brisk  purgation 
being  an  important  indication.  i\.ntiphlogistic  remedies  should  be  admin- 
istered, aconite,  veratrum  viride,  and  tartar  emetic  being  the  best  of  these. 
Aconite  or  veratrum  should  be  alternated  with  small  doses  of  the  mild  chlo- 
rid  of  mercury  in  combination  with  opium  after  the  English  fashion.  The 
opiate  should  be  given  in  sufficient  doses  to  relieve  pain.  It  probably  directly 
inhibits  the  inflammation.  Pulsatilla  is  often  beneficial.  Our  homeopathic 
brethren  consider  this  drvig  a  specific  for  testicular  and  ovarian  inflamma- 
tion. After  local  depletion  by  leeching,  hot  narcotic  poultices  should  be 
applied.  These  should  be  made  of  equal  parts  of  fine-cut  tobacco  and  lin- 
seedmeal,  liberally  sprinkled  with  tincture  of  opium.  They  should  be  fre- 
quently changed,  else  they  will  prove  harmful;  nothing  is  more  injurious 
in  acute  inflammation  than  alternations  of  heat  and  cold.  Should  the  in- 
flammation prove  severe,  and  remedies  fail  to  abate  it,  the  tunica  albuginea 
should  be  incised  subcutaneously. 

The  operation  should  be  performed  with  a  small  tenotome.  A  single 
puncture  is  made  in  the  scrotum,  preferably  at  its  lower  part,  and,  the  testis 
being  steadied,  a  number  of  incisions  are  made  through  its  fibrous  capsule. 
From  two  to  six  short  cuts  should  be  made,  care  being  taken  not  to  cut  too 
deeply,  as  it  is  desirable  to  avoid  wounding  the  secreting  structure  of  the 
testis  if  possible.  This  operation  relieves  tension  and  produces  direct  de- 
pletion of  the  affected  organ,  and  if  performed  early  is  likely  to  prevent 
suppuration  and  gangrene. 

As  orchitis  subsides,  electricity  should  be  used,  with  the  view  of  pre- 
venting atrophy  if  possible.  Atrophy  is  generally  resistant  to  treatment, 
but  electricity  may  perhaps  be  beneficial,  even  after  shrinking  of  the  testis 
has  begun. 

If  abscesses  form  they  should  be  opened  as  soon  as  fluctuation  is  de- 
tected, care  being  taken  to  injure  the  testis  as  little  as  possible.  The  open- 
ing should  be  kept  patent  for  a  time,  as  there  is  danger  of  a  pocket's  being 
formed,  causing  still  more  extensive  abscess  and  fistula. 

Should  a  fistula  resrdt  from  the  abscess  and  be  slow  in  closing,  astrin- 
gent or  stimulating  injections  may  be  used.    These  failing,  a  probe  coated 


946  IXFLAMilATOET   AFFECTIOXS    OF    THE    TESTIS. 

with  iodin  or  a  fused  bead  of  nitrate  of  silver  may  be  passed  along  the 
fistulous  track  to  its  bottom. 

The  administration  of  tonics,  judicious  stimulation  of  the  sinuses,  and 
perhaps  a  change  of  air  will  in  time  effect  a  cure  in  the  majority  of  cases. 
Should  the  fistula  continue  to  discharge,  or  new  ones  form  from  time  to 
time,  the  patient  becoming  debilitated,  free  incision  is  indicated,  and,  this 
failing,  castration  is  demanded.  To  decide  upon  the  removal  of  a  testicle 
diseased  in  this  manner  requires  excellent  judgment.  Certain  it  is  that  the 
organ  should  not  be  removed  while  there  is  reasonable  prospect  of  healing, 
especially  if  the  general  health  remains  fair.  Conservatism,  on  the  other 
hand,  may  lead  to  the  most  disastrous  results  through  the  development  of 
local  caseous  or  tubercular  changes  and  general  systemic  infection. 

Fungus  of  the  testis — hernia  testis — should  be  treated  by  strapping  and 
occasional  cauterizations  with  silver  nitrate.  The  mass  should  not  be  pulled 
upon  or  cut  away,  as  a  rule,  for  it  may  contain  a  quantity  of  comparatively 
healthy  tubuli  seminiferi  that  should  be  saved  if  possible.  Should  strap- 
ping fail,  the  fungus  should  be  removed  aseptically  and  an  attempt  made  to 
obtain  primary  closure  of  the  overlying  tissues. 

EPIDIDYMITIS. 

Epididymitis  is  the  most  frequent  and  important  disease  of  the  testis. 
It  is  important  not  only  because  of  its  painful  character  and  intimate  asso- 
ciation with  gonorrhea,  but  also  from  its  liability  to  produce  permanent  in- 
jury with  perhaps  complete  loss  of  function  of  the  afEected  organ.  This  is 
especially  important  in  view  of  the  fact  that  the  remaining  testis,  if  there 
be  one,  may  subsequently  become  the  seat  of  inflammation  or  injury,  as  a 
consequence  of  which  the  procreative  power  is  completely  abolished. 

Many  writers  upon  genito-urinary  and  venereal  diseases  have  written 
exhaustively  upon  epididymitis,  but  in  most  instances  the  disease  has  been 
confounded  with  orchitis  by  the  earlier  authors.  Some  of  the  more  modern 
writers  have  also  confused  the  two  affections,  or,  at  least,  have  failed  to 
differentiate  them  clearly.  Thus,  Milton  describes  inflammation  of  the  testis 
under  the  omnibus  term  "orchitis."^  This  is  peculiar,  for  Milton's  knowl- 
edge of  the  pathology  of  testicular  inflammation  is  unexceptionable. 

Epididymitis  necessarily  occurs  most  frequently  between  the  ages  of 
puberty  and  thirty  years, — the  period  during  which  the  individual  is  most 
likely  to  be  licentious, — the  most  frequent  cause  of  the  affection  being  in- 
flammation or  other  organic  disease  of  the  urethral  mucous  membrane.  The 
inflammation  is  usually  limited  to  one  testis,  double  epididymitis  being  quite 
rare.  In  case  of  double  inflammation  both  organs  are  very  rarely  attacked 
simultaneously.  The  author  recalls  a  case,  however,  of  a  man  suffering  from 
an  attack  of  epididymitis  in  the  right  testis,  the  left  one  being  at  the  same 


^  "Gonorrhea  and  Spermatorrliea,"  J.  L.  Milton. 


ETIOLOGY    OF    EPIDIDYMITIS.  947 

time  tender  and  painful.  Within  forty-eight  hours  after  swelling  began  in 
the  right  testis  the  left  organ  also  began  to  swell,  attaining  a  size  almost 
as  great  as  that  of  the  organ  primarily  affected.  The  literature  goes  to  show 
that  few  cases  of  this  kind  have  been  observed.  Fournier  states  that  he  has 
never  seen  double  simultaneous  epididymitis.  Van  Buren  relates  a  single 
case,  in  which  the  inflammation  appears  to  have  been  subacute. 

The  inflammation  not  only  affects  the  epididymis,  but  also  the  serous 
investment  of  the  organ,  causing  so-called  acute  hydrocele,  which  is  simply 
an  acute  inflammatory  serous  effusion  into  the  cavity  of  the  tunica  vaginalis. 
The  distension  of  the  serous  membrane  by  the  effused  fluid  is  the  principal 
cause  of  the  agonizing  pain  experienced  in  some  cases  of  epididymitis. 

Etiology. — The  immediate  causes  of  epididymitis  are  not  numerous. 
Nearly  all  cases  occur  as  a  direct  result  and  complication  of  urethritis,  espe- 
cially the  virulent  form.  The  simpler  varieties  of  urethritis  are  not  so  liable 
to  give  rise  to  it.  The  liability  to  epididymitis,  however,  appears  to  be 
directly  proportionate  to  the  degree  of  the  urethritis  rather  than  dependent 
upon  any  specific  character  of  the  urethral  disease.  When,  however,  simple 
urethritis  co-exists  with,  or  is  dependent  upon,  organic  stricture;  granular, 
congested  patches  of  the  urethra;  or  any  chronic  infectious  process,  a  very 
slight  increase  in  the  inflammation  is  apt  to  precipitate  epididymitis.  In 
urethral  stricture  very  simple  causes  may  excite  inflammation  of  the  testis. 
The  passage  of  instruments,  even  in  the  hands  of  the  most  expert  surgeon, 
may  give  rise  to  it  by  setting  up  more  or  less  marked  acute  infection  and 
inflammation  in  and  about  the  diseased  urethrah  area,  which  extends  down- 
ward into  the  deeper  portion  of  the  canal  and  finally  affects  the  testis.  After 
the  instrument  conveys  infection  directly  to  the  mouths  of  the  ejaculatory 
ducts  patients  with  chronic  gleet,  stricture,  and  granular  or  abraded  patches 
in  the  urethra  are  continually  predisposed  to  epididymitis.  Sexual  excess, 
prolonged  ungratified  sexual  desire,  indulgence  in  alcoholics,  and  exposure 
to  cold  and  wet  may  all  serve  as  exciting  causes.  A  certain  proportion  of 
cases  of  epididymitis  probably  have  for  their  principal  predisposing  cause  a 
rheumatic  or  gouty  constitution. 

In  patients  of  a  rheumatic  or  gouty  diathesis,  comparatively  slight  ex- 
citing causes  are  sufficient  to  develop  inflammation  of  the  testis.  Such  pa- 
tients, while  under  treatment  for  urethral  disease,  will  often  develop  epididy- 
mitis without  apparent  cause.  Experience  shows  that  in  such  patients  great 
caution  is  necessary  in  tampering  with  the  urethra.  In  proof  of  the  cor- 
rectness of  this  assertion,  a  certain  proportion  of  cases  of  epididymitis  that 
tend  to  run  a  subacute  or  moderately  chronic  course  under  ordinary  treat- 
ment will  go  on  to  resolution  very  rapidly  under  the  internal  administration 
of  colchicum,  potassium  iodid,  or  sodium  salicylate,  alone  or  in  combina- 
tion. The  sodium  salicylate,  especially,  is  often  very  efficacious.  A  consid- 
erable number  of  cases  present  themselves  in  which  no  physical  signs  can 
be  detected,  nor  can  any  history  of  antecedent  urethral  disease  be  elicited. 


948  IXFLAMMATOEY    AFFECTIOXS    OF    THE    TESTIS. 

Such  cases  are  not  infrequent  in  disjjensar}'  practice;  and,  making  due  allow- 
ance tor  the  proverbial  unreliability  of  such  patients,  there  still  remains  a 
certain  number  of  cases  that  may  be  rationally  attributed  to  rheumatic  in- 
flammation of  the  testis  and  its  envelopes.  In  some  of  these  cases,  perhaps, 
traumatism  is  an  important  causal  element;  but  in  the  absence  of  predis- 
position it  is  a  question  whether  acute  or  subacute  inflammation  of  the 
testis  could  be  produced  by  an  injury  so  slight  as  to  be  unnoticed  at  the  time 
of  its  occurrence.  This  is  especially  doubtful  if  the  extreme  sensitiveness  of 
the  organ  be  considered.  The  following  case  from  private  practice  illus- 
trates what  would  appear  to  be  rheumatic  epididymitis: — 

Case. — A  young  man,  30  years  of  age,  had  been  under  the  author's  professional 
care  for  a  number  of  years.  He  had  neyer  had  any  venereal  disease,  but  had  suffered 
from  several  attacks  of  articular  rheumatism.  A  short  time  since  he  developed  an 
acute  enlargement  of  the  testes.  This  came  on  quite  suddenly  after  exposure  to  cold 
and  wet,  following  a  slight  injury  to  the  organ.  The  patient  stated  that  the  injury- 
was  so  slight  that  he  should  never  have  thought  of  it  again  had  not  the  epididymitis 
developed  a  week  or  ten  days  later.  The  inflammation  was  not  severe  from  the 
beginning,  and,  although  the  swelling  of  the  epididymis  and  effusion  into  the  tunica 
vaginalis  were  considerable,  there  had  been  only  moderate  pain,  and  the  patient  had 
continued  at  his  work,  which  required  considerable  movement.  There  was  no  evi- 
dence of  urethral  inflammation,  and  subsequent  exploration  excluded  stricture.  The 
testicle  was  considerably  enlarged,  the  scrotum  moderately  swelled  and  edematous, 
and  the  organ  moderately  tender  on  pressure.  Under  free  doses  of  colchicum  and 
salicylate  of  soda,  with  small  doses  of  iodid  of  potassium,  the  testis  was  reduced  to  its 
natural  size  in  about  three  weeks.  There  was  no  reason  to  suspect  syphilis  in  this 
case,  nor  were  there  any  evidences  of  that  disease  upon  examination. 

A  case  of  what  may  reasonably  be  styled  rheumatic  epididymitis  is  re- 
ported by  Keyes,  as  follows: — 

Case. — A  healthy  coachman  driving  during  a  cold  rain  sat  for  some  hours  in  a 
pool  .of  cold  water  which  collected  upon  the  leather  cushion  under  him.  On  the 
following  day  he  was  attacked  with  a  perfectly  characteristic  epididymitis,  which 
ran  the  usual  course  without  affecting  the  secreting  jjortion  of  the  testicle,  and 
terminated  in  resolution. 

The  relation  of  latent  infection  of  the  deep  urethra  and  prostate  to 
epididymitis  is  a  most  important  one.  Epididymitis  occurring  without  ap- 
parent cause  is  usually  due  to  deep  infection  from  an  almost,  or  even  quite, 
forgotten  gonorrhea.  Chronic  urethral  or  prostatic  disease  is  often  respon- 
sible for  cases  in  which,  without  exciting  cause,  successive  attacks  of  in- 
flammation of  the  testis  occur — relapsing  epidid3'mitis. 

Injuries  of  the  testis  are  quite  apt  to  be  followed  by  epididymitis — with 
or  without  orchitis.  In  this  traumatic  inflammation  there  is  danger  of 
infection  and  acute  abscess  or  gangrene  and  sloughing,  with  consequent  dan- 
ger of  permanent  impairment  or  even  destruction  of  the  organ.  If,  as  oc- 
casionally happens,  the  inflammation  is  complicated  by  hematocele,  the  con- 
dition is  very  serious. 


ETIOLOGY    OF    EPIDIDYMITIS.  9i9 

Admitting  that  infection  from  tlie  urethra  is  the  most  frequent  cause 
of  epididymitis,  its  modus  operandi  is  of  great  interest  and  importance.  It 
was  long  supposed  that  epididjanitis  resulted  from  a  sudden  delitescence  or 
jumping  of  the  inflammation  from  the  urethral  mucous  membrane  to  the 
testis,  this  process  being  termed  metastasis.  The  modern  pathologist,  how- 
ever, is  not  content  with  such  an  illogical  explanation.  Inflammation  of 
the  testis  occurring  in  the  course  of  acute  urethritis  no  more  results  from 
so-called  metastasis  than  does  the  peculiar  form  of  inflammation  of  synovial 
and  fibrous  structures  sometimes  occurring  in  the  same  disease.  Both  are 
due  to  the  action  of  the  products  of  the  mixed  infection  of  virulent  ure- 
thritis transmitted  in  some  manner  to  the  affected  structures.  The  gono- 
coccus  has  been  discovered  in  the  fluid  of  joints  affected  by  gonorrheal 
inflammation.  This  has  been  proved  by  culture-tests,  but,  independently 
of  this,  clinical  evidence  tends  to  show  the  dependence  of  gonorrheal 
rheumatism  upon  absorption  of  infectous  products — toxins — from  the 
urethra.  It  may  be  accepted  that  some  cases  of  epididymitis  are  due  to 
absorption  of  the  irritating  infectious  products  of  urethral  inflammation  and 
their  conveyance  to  the  sensitive  structures  of  the  epididymis.  That  the 
gonococcus  is  not  the  essential  factor  has  been  shown  by  experiments  upon 
animals:  a  pseudo-alkaloid  has  been  extracted  from  gonorrheal  pus  which 
is  capable  of  producing  testicular  inflammation  in  dogs. 

In  most  instances  epididymitis  is  probably  the  result  of  direct  backward 
extension  of  urethritis.  'The  germs  and  germ-products  of  the  mixed  infec- 
tion pass  backward  into  the  prostatic  urethra,  infect  the  orifices  of  the  ejacu- 
latory  ducts,  enter  the  vas  deferens,  and,  finally  arriving  at  the  epididymis, 
excite  inflammation  therein.  That  such  extension  occurs  is  indubitable. 
Milton  insists  that  this  method  of  infection  is  constant.     He  says: — 

Even  those  who  accept  the  theory  of  sympathy  confess  that  sometimes  the  in- 
flammation spreads  along  the  urethra:  a  surmise  proved  by  the  cases  which  Cooper, 
Ricord,  Gay,  and  others  have  recorded;  hut  several  symptoms  concur  to  make  it 
almost  certain  that  this  is  always  a  fact.  Tenderness  of  the  urethra  as  far  back  as 
the  prostate  is  constant  in  such  cases.  Perineal  pain  and  tenderness  in  the  vas 
deferens,  very  frequently  spasm,  stricture,  and  great  vesical  irritability,  precede  swell- 
ing of  the  testicle.  Orchitis  often  follows  from  irritation  of  these  parts  just  as  it 
occurs  from  stricture  or  stone.  No  doubt,  at  the  beginning  and  in  mild  cases,  the 
first  inch  and  a  half  of  the  urethra  may  be  looked  upon  as  the  seat  of  gonorrheal  in- 
flammation; but  later  on  the  case  is  very  different.  It  is  not  at  all  uncommon  for 
gonorrhea,  even  in  cases  unaccompanied  by  orchitis,  to  extend  at  least  five  or  six 
inches  down  the  urethra,  and  often  quite  to  the  bladder.  It  is  true  that  the  history 
may  reveal  nothing  pointing  to  this  conclusion.  Sensation  is  often  so  dull  in  the 
posterior  poi-tion  of  the  spongy  part  that,  if  a  bougie  has  passed  the  first  two  inches 
or  so,  the  patient  cannot  tell  within  an  inch  where  the  point  is;  but  a  very  simple 
experiment  will  often  show  that  though  the  sensation  may  reveal  nothing,  the  in- 
flammation has  reached  as  far  as  I  have  said.  The  surgeon  has  only  in  a  few  bad 
cases  of  gonorrhea  or  gleet  to  syringe  out  the  urethra  with  cold  water  up  to  the 
posterior  end  of  the  so-called  specific  seat  of  the  disease,  then  direct  the  patient  to 
make  water.     In  a  certain  proportion  of  cases  a  shred  or  two  of  muco-pus  will  be 


950  IXFLAMMATORT    AFFECTION'S    OF    THE    TESTIS. 

expelled.  Again,  if  a  bougie  be  passed  for  two  or  three  inches,  withdrawn,  wiped 
clean,  and  passed  down  to  the  membranous  or  prostatic  portion  of  the  canal,  a  shred 
or  two  will  often  be  found  upon  it  when  withdrawn.  In  obstinate  gleet  the  bougie 
in  passing  over  the  posterior  portion  of  the  urethra  often  encounters  tender  spots; 
with  the  removal  of  this  tenderness  the  gleet  ceases.  Injecting  the  posterior  urethra 
will  often  cure  gleet,  where  large  injections  of  every  kind  applied  to  the  anterior 
part  of  the  canal  have  totally  failed.  In  short,  we  see  in  all  the  phenomena  of 
orchitis  the  disease  passing  along  continuous  and  contiguous  structures  just  as  in 
other  parts;  nothing  tells  us  that  the  two  extreme  points  of  the  membrane  are  in- 
flamed and  the  tract  between  them  sound. 

The  probability  is  that  the  sympathetic  variety  described  by  Eieord,  Curling, 
Egan,  and  others  implies  a  mild  form  of  extension  of  inflammation,  those  parts  which 
intervene  being  from  their  low  organization  incapable  of  active  disease  of  this  kind, 
it  being  well  known  to  surgeons  that  the  portion  of  the  urethra  between  the  specific 
seat  of  gonorrhea  and  the  membranous  tract  is  much  less  sensitive  than  these  regions. 
The  older  surgeons  knew  this  as  well  as  modem  writers.  Indeed,  Sir  Astley  Cooper 
described  orchitis  as  beginning  with  irritation  of  the  membranous  or  prostatic  portion 
of  the  canal  and  tenderness  of  the  spermatic  cord,  while  Hunter  alludes  to  similar 
facts.  Swediaur  maintained  that  orchitis  was  due  to  the  poison's  reaching  the 
mouths  of  the  ejaculatory  ducts;  and  Bell  and  Civiale  pointed  out  the  affection  of 
the  cord.  Johnson  gives  an  analysis  of  59  cases,  in  12  of  which  the  symptoms  of 
urethritis  were  entirely  gone  before  the  orchitis  came  on,  and  the  evidence  of  MM. 
Castelnau  and  Aubiy  is  to  the  effect  that  this  complication  may  appear  from  five 
days  to  three  months  after  cessation  of  discharge. 

American  surgeons  are  hardly  credulous  enough  to  deem  the  sympa- 
thetic theory  of  testicular  inflammation  worthy  of  attention.  The  gradual 
downward  extension  of  infection,  or  the  transference  of  germs  to,  and  in- 
oculation of,  the  prostatic  urethra  by  instruments  is  sufficient  explanation 
of  the  cases  supposed  by  the  older  surgeons  to  be  sympathetic.  It  should 
be  remembered  that  infection  may  traverse  the  deeper  portion  of  the  pendu- 
lous urethra  and  involve  the  deep  urethra  proper  without  necessarily  caus- 
ing inflammation  of  the  intervening  mucous  membrane.  The  virulency  of 
the  infection  in  the  first  few  inches  of  the  pars  pendulosa  may  be  sufficiently 
diminished  to  obviate  extension  of  inflammation  or  infection  to  its  posterior 
part,  although  still  perfectly  capable  of  producing  infectious  inflammation 
in  the  relatively  delicate  prostatic  urethra.  Another  point  worthy  of  com- 
ment is  the  fact  that — in  the  author's  opinion — the  venereal  orgasm  is  often 
responsible  for  epididymitis  by  causing  suction  in  the  deep  urethra  which 
draws  infectious  products  of  anterior  inflammation  into  the  prostatic  urethra. 
Epididymitis  very  frequently  follows  soon  after  sexual  indulgence  in  gonor- 
rheic  patients.  This  argument  is  equally  cogent,  whether  the  specificity  of 
gonorrhea  be  admitted  or  not. 

As  illustrating  epididymitis  from  extension,  the  following  case  is  of 
interest: — 

Case. — A  young  man,  the  son  of  a  physician,  had  been  under  the  author's  care 
for  a  moderately  severe  attack  of  urethritis.  Contrary  to  advice,  he  continued  drink- 
ing and  active  exercise.  The  author  was  called  at  night  by  the  patient's  father, — 
who  was  ignorant  of  his  son's  condition, — with  instructions  to  bring  instruments  for 


ETIOLOGY    OF    EPIDIDYMITIS.  951 

operating  upon  strangulated  hernia.  The  mistake  was  not  surprising,  for  the  sper- 
matic cord  within  the  inguinal  canal  was  swelled  and  excessively  tender,  giving  rise 
from  simple  strangulation  to  symptoms  not  unlike  those  of  strangulated  hernia.  By 
the  evening  of  the  following  daj'-  the  inflammation  had  traversed  the  remainder  of 
the  spermatic  cord  and  invaded  the  epididymis,  the  swelling  of  which  cleared  up  the 
diagnosis. 

The  foregoing  ease  is  but  one  of  a  large  number  in  tlie  autbor^s  ex- 
perience. 

Eicord  expresses  himself  regarding  the  theory  of  extension  as  follows: — 

A  fact  important  to  be  observed  is  that  there  are  two  varieties  of  epididymitis: 
the  one  sympathetic,  when  the  epididymis  alone  is  affected;  the  other  from  extension 
or  from  continuity  of  the  tissue  or  by  extension  of  the  inflammation,  when  it 
extends  from  the  urethra  to  the  canalis  ejaculatorius,  thence  to  the  vesiculw  semi- 
nales  and  vas  deferens,  and  lastly  to  the  epididymis  as  demonstrated  by  pathologic 
anatomy. 

Epididymitis  has  been  attributed  to  the  use  of  injections.  This  cause 
has  been  disputed,  but  there  is  little  doubt  that  injections  are  responsible 
for  quite  a  proportion  of  cases.  Injections  give  rise  to  epididymitis  in  two 
ways:  1.  Strong  injections  set  up,  chemically,  inflammation  of  the  pro- 
static urethra,  which  extends  in  the  usual  manner  to  the  testis.  2.  The 
injection,  whether  weak  or  strong,  mechanically  forces  some  of  the  gonor- 
rheal virus  into  the  deep  urethra. 

In  respect  to  the  first  method,  it  is  probable  that  injections  are  rarely 
used  strong  enough  to  be  capable  per  se  of  exciting  deep  urethral  inflamma- 
tion. The  general  sentiment  of  the  profession  at  the  present  day  is  rather 
against  strong  urethral  injections.  An  injection  must  certainly  be  very 
strong  to  be  capable  of  chemically  exciting  urethral  inflammation.  With- 
out being  strong  enough  to  excite  such  inflammation  directly,  however,  it 
may  be  irritating  enough  to  enhance  existing  urethritis,  thus  favoring  its 
extension  into  the  deep  urethra. 

The  second  cause  is  probably  very  often  operative,  independently  of  the 
strength  of  the  injection.  An  injection  of  simple  water,  if  incautiously  used 
and  injected  deeply,  may  excite  epididymitis  by  carrying  gonorrheal  poison 
into  the  prostatic  urethra,  perhaps  forcing  it  directly  into  the  mouths  of 
the  ejaculatory  ducts.  As  will  be  seen  in  connection  with  the  diseases  of 
the  bladder,  gonorrheal  cystitis  may  occasionally  be  caused  in  a  precisely 
similar  manner.  It  is  probable  that  comparatively  mild  injections  are  more 
apt  to  excite  epididymitis  than  those  of  moderate  strength,  particularly  if 
antiseptic  in  character.  Mild  fluids  might  fail  to  destroy  the  gonorrheal 
infection,  as  it  is  carried  into  the  deeper  portions  of  the  urethra.  In  the 
author's  experience  epididymitis  has  grown  much  less  frequent  since  adopt- 
ing the  routine  practice  of  instructing  the  patient  thoroughly  in  the  use  of 
the  urethral  syringe.  In  most  eases  patients  have  referred  the  trouble  to 
some  particular  injection,  in  the  performance  of  which  the  fluid  was  forced 


953  INPLAMMATOEY    AFFECTIONS    OF    THE   TESTIS. 

deeply  into  the  jDerineal  urethra,  the  direct  result  of  this  being  considerable 
irritation  about  the  vesical  neck,  followed  by  swelling  of  the  testicle  within 
twenty-four  to  forty-eight  hours. 

The  surgeon  is  very  often — unavoidably  or  otherwise — responsible  for 
epididymitis.  The  introduction  of  instruments  during  the  existence  of  an 
acute  gonorrhea  is  especially  apt  to  give  rise  to  testicular  complications. 
Not  only  does  the  instrument  enhance  the  inflammation  already  existing, 
but  it  carries  deeply  into  the  canal  the  mixed  infection  of  gonorrhea.  This 
has  seemed  to  be  the  principal  objection  to  the  routine  practice  of  retro- 
injection  in  gonorrhea.  No  matter  how  carefully  the  operation  may  be  per- 
formed, more  or  less  irritation  seems  to  be  unavoidable,  and,  in  any  case  in 
which  the  instrument  is  passed  deeply  into  the  canal,  deep-urethral  infec- 
tion and  inflammation  are  likely  to  result. 

In  certain  cases  of  chronic  urethritis  and  organic  stricture  epididymitis 
follows  even  the  careful  passage  of  instruments.  If  the  surgeon  be  at  all 
rough  and  unskillful,  he  is  certain  to  have  a  liberal  proportion  of  cases  of 
this  complication.  Patients  under  treatment  for  stricture,  even  in  the  best 
of  hands,  are  constantly  predisposed  to  epididymitis,  particularly  if  they  be 
rheumatic  or  gouty,  or  intemperate  in  eating,  drinking,  or  sexual  indul- 
gence. A  debauch,  prolonged  sexual  excitement,  and  exposure  to  wet  and 
cold  are  all-sufficient  causes  for  epididymitis  in  a  patient  who  is  under  treat- 
ment for  stricture.  Accidents  of  this  kind  are  not  only  unpleasant  for  the 
victim,  but  it  is  often  difficult  thereafter  for  the  surgeon  to  regain  the  pa- 
tient's confidence. 

It  has  been  asserted  that  the  balsams  in  some  instances  produce  so  much 
stimulation  of  the  genito-urinary  tract  that  epididymitis  is  excited.  This 
does  not  seem  reasonable,  for  the  stimulating  influence  of  balsamic  prepara- 
tions is  certainly  very  mild.  Cubebs,  copaiba,  and  sandal-wood  are  changed 
in  their  passage  through  the  kidneys  into  a  substance,  which,  though  mod- 
erately stimulating  to  the  mucous  membrane,  is  certainly  bland  enough  to 
be  incapable  of  exciting  inflammation.  Acute  urethritis,  while  not  so  mark- 
edly benefited  by  the  balsams  as  the  later  stages  of  the  affection, — in  which 
Nature  herself  is  rapidly  bringing  about  a  cure  in  a  large  proportion  of  cases, 
— is  nevertheless  usually  improved  by  them. 

Morbid  Anatomy. — The  morbid  anatomy  of  epididymitis  is  of  interest. 
Opportunities  for  its  study,  however,  are  relatively  rare,  as  the  disease  is 
not  intrinsically  fatal.  Dissection  shows  the  epididymis  to  be  considerably 
enlarged,  frequently  to  three  or  four  times  its  normal  size.  It  is  hard  and 
nodular,  the  swelling  being  in  some  cases  greater  at  one  point  than  another; 
thus,  in  some  instances  the  body  of  the  epididymis  is  relatively  larger  than 
the  extremities,  while  in  others  one  or  the  other  end  is  largest.  The  walls 
of  the  convoluted  tube  constituting  the  epididymis  are  thickened  and  in- 
filtrated; its  mucous  lining  thickened,  highly  injected,  and  vascular;  and 
its  lumen  occluded  by  plastic  lymph.     The  convolutions  of  the  tube  are 


MORBID    ANATOMY    OF    EPIDIDYMITIS. 


953 


fused  together  in  an  indistinguishable  mass  by  plastic  exudate.  The  testis 
proper  is  comparatively  rarely  enlarged;,  although  the  tunica  albuginea  may 
be  more  or  less  thickened.  In  some  cases,  as  already  indicated,  the  body  of 
the. testis  is  involved  in  an  enlargement  similar  to  that  seen  in  primary 
acute  orchitis.  The  whole  testis,  as  well  as  its  serous  envelope,  is  injected 
and  reddened.  The  vas  deferens  is  thickened  for  a  variable  distance  above 
the  testicle.  Where  the  inflammation  has  resulted  from  simple  extension  via 
the  vas  deferens,  the  latter  will  be  found  to  be  enlarged  and  indurated  as 
far  as  it  can  be  traced  into  the  inguinal  canal;  in  fact,  the  canal  itself  will 
be  found  to  be  swollen  by  the  contained  spermatic  cord.  The  lymphatics 
of  the  spermatic  cord  are  apt  to  be  involved  and  the  entire  cord  thickened 
from  extension  of  inflammation  from  the  vas  deferens.  There  is  usually 
a  considerable  amount  of  fluid  in  the  tunica  vaginalis;  this,  however,  de- 
pends entirely  upon  the  acuteness  of  the  inflammation;   the  more  acute  the 


Fig.  218. — Acute  epididymitis.     (After  Monod  and  Terrillon.) 


process,  the  more  abundant  the  fluid.  Later  on  in  the  course  of  the  disease 
the  fluid  will  be  found  to  have  absorbed,  wholly  or  partially,  and  there  may 
be  a  small  quantity  of  soft  coagulable  lymph  within  the  cavity  of  the  tunica 
vaginalis,  the  whole  process  strongly  resembling  acute  pleurisy. 

The  thickening  of  the  convoluted  tubular  structure  of  the  ejDididymis 
and  the  deposition  of  plastic  lymph  in  and  about  it  are  of  great  importance, 
for,  if  the  exudate  is  extensive  and  becomes  permanently  organized,  it  may 
occlude  the  lumen  of  the  e23idid5'^mis  and  vas  deferens,  preventing  the  pas- 
sage of  the  spermatic  fluid  and  thus  entailing  sterility  so  far  as  the  affected 
testis  is  concerned.  Should  the  opposite  organ  ever  become  similarly  af- 
fected complete  sterility  is  to  be  expected,  though  sexual  potency  may  still 
be  unimpaired. 

In  a  case  of  the  authors  one  testis  was  removed  because  of  tubercular 
disease.     The  remaining  organ  was  subsequently  affected  by  epididymitis. 


954  INFLAMMATORY   AFFECTIOiSrS    OF    THE    TESTIS. 

with  resultant  marked  induration.  The  power  of  copulation  and  the  sen- 
sation of  orgasm  were  subsequently  perfect,  hut  without  emission. 

Time  of  Oxset. — The  period  at  which  epididymitis  develops  in  the 
course  of  gonorrhea  is  variable,  depending  largely  uj)on  the  character  of  the 
treatment  and  the  habits  of  the  patient.  Inflammation  of  the  testicle  will 
be  likely  to  come  on  early  if  injections  are  carelessly  given  or  if  instruments 
are  introduced  into  the  deep  urethra,  thus  conve3dng  the  infection  to  the 
deeper  parts.  In  cases  that  are  not  interfered  with  in  this  manner  the  dis- 
ease does  not  usually  appear  until  after  the  first  week.  According  to  Four- 
nier,  epididymitis  occurred  in  220  cases  as  follows: — 

Total  number  of  eases  occurring 

In  the  first  Aveek 0 

In  the  second  week 22 

In  the  third  week 34 

In  the  fourth  week 30 

In  the  fifth  weet 29 

In  the  sixth  week 19 

In  the  seventh  week 9 

In  the  eighth  week 21 

In  the  first  month 86 

In  the  second  month 78 

In  the  third  month 22 

In  the  fourth  month 6 

In  the  fifth  month 6 

In  the  sixth  month 4 

In  the  seventh  month 3 

In  the  eighth  month 3 

In  the  ninth  month 4 

Of  these  eases,  most  of  those  occurring  after  the  third  month,  at  which 
time  there  is  a  marked  diminution  in  the  number  of  eases,  were  probably  due 
to  causes  other  than  mere  spontaneous  extension  of  infectious  inflamma- 
tion. All  along  the  line  of  cases  there  probably  existed  certain  exciting 
causes  that  Fournier  has  apparently  ignored.  Thus,  strong  injections,  tam- 
pering with  the  urethra,  sexual  excesses,  prolonged  ungratified  excitement, 
intemperance,  fatigue  and  overexertion,  exposure  to  cold  and  wet,  and  in- 
tercurrent diseases  of  various  kinds  may  have  been  the  exciting  causes  in 
many  of  these  cases. 

The  majority  of  cases  occur  after  the  third  week,  and  according  to  the 
foregoing  table  more  cases  seem  to  develop  in  the  fifth  and  sixth  weeks  than 
at  any  other  time.  Epididymitis  often  develops  some  little  time  after  the 
urethritis  is  apparently  well.  These  eases  are  due  either  to  latent  posterior 
urethral  infection  or  to  an  anterior  infection,  existing  without  symptoms, 
that  suddenly  extends  to  the  deep  urethra.  In  either  case  there  may  be  some 
exciting  cause,  but  this  is  not  essential.  It  is  interesting  to  note  that  Vel- 
peau  long  ago  explained  such  cases  by  the  existence  in  the  deeper  portions 


TIME    OF    OKSET    OF    EPIDIDYMITIS.  955 

of  the  urethra,  or  about  the  vesical  neck,  of  a  slight  degree  of  inflammation 
which  does  not  give  rise  to  external  discharge.  This  well  accords  with  our 
modern  views  of  latent  deep  infection.  It  has  been  shown  that  gonococci 
may  remain  in  this  iDortion  of  the  urethra  for  a  long  time,  and  suddenly  be- 
come increased  in  activity  and  infectious  properties  from  some  unknown 
cause.  The  germs  and  germ-products  of  mixed  infection  are,  however,  more 
important  in  this  regard. 

Cases  have  been  reported  in  which  epididymitis  developed  prior  to  the 
appearance  of  urethral  discharge.  Taylor,  Castelnau,  Vidal,  and  Velpeau 
admit  the  occurrence  of  such  cases.  In  such  cases  the  cause  is  either  inde- 
pendent of  urethritis  altogether  or  an  old  latent  infection  exists. 

In  a  certain  number  of  cases  epididymitis  exhibits  a  tendency  to  relapse. 
This  has  been  attributed  by  some  authors  to  certain  atmospheric  conditions.' 
Cold  and  wet  weather  seem  to  bear  a  positive  relation  to  the  occurrence  of 
epididymitis.  This  favors  the  opinion  already  expressed  that  quite  a  pro- 
portion of  cases  are  dependent  upon  rheumatic  predisposition.  Milton  has 
prepared  an  elaborate  table  for  the  purpose  of  demonstrating  the  relation 
that  alterations  in  the  electric  tension  of  the  atmosphere  bear  to  the  occur- 
rence of  inflammation  of  the  testis.  He  has,  however,  failed  to  demonstrate 
any  positive  facts  for  or  against  the  theory.  Urethral  and  bladder  diffi- 
culties, and,  incidentally,  inflammation  of  the  testicle,  are  more  liable  to 
relapse  during  the  changeable  raw  weather  of  the  late  autumn  or  early 
spring.  Excessive  secretion  of  semen  from  intense  venereal  excitenient  pre- 
disposes to  epididymitis,  and  especially  to  the  relapsing  form.  The  condi- 
tions favorable  to  relapse  are  a  tender  and  irritable  condition  of  the  testis, 
which  necessarily  exists  some  time  after  the  acute  inflammation  has  sub- 
sided, and  more  or  less  obstruction  to  the  exit  of  the  seminal  fluid  from  the 
testicle.  This  obstruction  does  not  always  exist,  but  in  a  certain  proportion 
of  instances  it  may  become  permanent;  and,  if  patients  thus  affected  are 
subjected  to  repeated  and  intense  sexual  excitement,  a  recurrence  or  relapse 
of  the  inflammation  is  quite  apt  to  occur.  Milton  says  with  reference  to 
this  point:  "Orchitis  of  this  kind  ensues  after  cutting  for  stone.  It  seems 
to  me  that  the  action  is  purely  reflex."  (?) 

In  a  general  way  the  author  accepts  relapsing  epididymitis — which  is 
usually  subacute — as  presumptive  evidence  of  chronic  urethral  infection, 
most  often  stricture  or  chronic  posterior  urethritis:  chronic  follicular  pros- 
tatitis.    Upon  the  cure  of  this  infection  that  of  the  epididymitis  depends. 

According  to  Bumstead  and  Taylor,  Curling,  Gossail,  and  Despine,  the 
right  testicle  is  affected  more  frequently  than  the  left.  This  differs  from 
the  earlier  observations  of  Sigmann,  who  found  in  over  1300  cases  that  the 
right  testicle  was  affected  in  only  one-third  of  the  number.  It  also  differs 
from  the  author's  own  experience.  No  logical  exjDlanation  has  been  given 
for  the  predilection  of  inflammation  for  the  left  testis,  nor,  indeed,  for  its 
limitation  in  almost  all  cases  to  a  sinorle  testis. 


956  INFLAiniATORY    AFFECTIONS    OF    THE    TESTIS. 

With  reference  to  the  testis  most  often  affected,  Eicord  speaks  as  fol- 
lows : — 

It  has  been  observed  that  the  left  testicle  is  most  frequently  affected.  The 
reason  of  this  greater  immunity  of  the  right  testicle  is,  according  to  the  observations 
made  in  my  wards  at  the  HojDital  des  Veneriens,  as  follows:  All  of  the  individuals 
who  carry  the  scrotum  on  the  left  side  of  the  seam  of  the  trousers — and  most  persons 
do  so — have  the  epididymitis  on  the  left  side,  and  vice  versa. 

Frequency. — There  is  no  constancy  in  the  freqnency  with  which  epi- 
didymitis complicates  gonorrhea.  In  one  series  of  cases  it  might  occur  in  a 
very  small  proportion,  perhaps  not  one  in  fifty;  while,  in  another,  every 
tenth  case  might  he  attacked.  This  is  explained  hy  the  great  variation  in 
methods  of  treatment  and  in  the  conduct  of  different  patients.  Some  indi- 
viduals follow  the  directions  of  the  i^hysician  implicitly:  take  the  necessary 
rest,  avoid  stimulants  and  sexual  excitement,  and  consequently  escape  epi- 
didymitis; others,  however,  develop  the  complication  by  self-treatment^  over- 
exertion, or  some  other  of  the  various  indulgences  known  to  excite  epididy- 
mitis. Fournier's  statistics  apparently  show  that  epididymitis  complicates 
about  every  eighth  or  ninth  case  of  clap. 

The  tendency  to  epidid3anitis  seems  to  be  modified  by  individual  pre- 
disposition, some  gonorrheal  patients  being  able  to  maltreat  themselves  with 
impunity  without  developing  inflammation  of  the  testis,  whilst  others,  wdio, 
perhaps,  take  the  very  best  care  of  themselves,  develop  it. 

Symptoms. — The  symptoms  of  epididymitis  are  usually  quite  acute,  but 
in  a  fair  proportion  of  cases  they  are  of  a  subacute  character.  The  patient 
is  usually  warned  of  impending  trouble  by  more  or  less  tenderness  and  ob- 
scure pain  in  the  organ,  with  slight  uneasy  and  dragging  sensations  refer- 
able to  the  spermatic  cord.  If  these  premonitory  symptoms  are  heeded, 
pronounced  inflammation  may  often  be  avoided  by  proper  management. 
During  the  premonitory  stage  of  the  disease  there  may  be  more  or  less  chilli- 
ness, general  depression  and  fever,  the  discharge  from  the  urethra  mean- 
while diminishing.  '  A  sudden  diminution  of  discharge,  associated  with  the 
foregoing  symptoms,  is  a  positive  indication  of  impending  epididymitis.  In 
some  instances  the  attack  is  very  sudden,  with  severe' pain  in  the  testis  radi- 
ating into  the  thighs,  groins,  and  possibly  through  the  back.  A  distinct 
chill  occurs  exceptionally.  Febrile  movement  is  usually  moderate,  but  may 
be  quite  high. 

There  are  sometimes  more  or  less  nausea  and  faintness,  due  to  the  pinch- 
ing of  the  delicate  nerve-supply  of  the  testis  by  inflammatory  exudate.  This 
is  especially  marked  where  the  inflammation  primarily  attacks  the  spermatic 
cord,  the  swelling  of  which  is  closely  confined  by  the  rigid  structures  of  the 
inguinal  canal.  The  first  symptom  occasionally  consists  in  pain,  tenderness, 
and  swelling  in  the  course  of  the  inguinal  canal.  This  may  precede  the  tes- 
ticular inflammation  by  some  hours.     Whenever  a  gonorrheal  patient  com- 


•  SYMPTOMS    OF    EPIDIDYMITIS.  90? 

plains  of  this  s}anptom,  epiclid3-mitis  is  to  be  apprehended.  Inflammation 
may  remain  limited  to  the  cord,  the  epididymis  escaping.  In  some  cases  the 
inflammatory  thickening  and  pain  in  the  spermatic  cord  persists  for  some 
time  after  the  swelling  of  the  testis  has  begun  to  decrease,  being  the  last 
symptom  to  disappear. 

Coincidently  with  the  development  of  the  subjective  symptoms  the  af- 
fected organ  begins  to  swell,  and  in  a  few  hours  may  be  considerably  enlarged, 
its  size  varying  with  the  amount  of  serous  effusion  in  the  tunica  vaginalis. 
When  the  effusion  is  abundant  the  pain  is  agonizing,  and  the  outline  of  the 
testicle  is  completely  obscured  by  the  tense  swelling  caused  by  the  fluid. 
Pain  and  tenderness  are  always  more  or  less  modified  by  the  nervous  sus- 
ceptibility of  the  patient.  The  scrotum  is  generally  swollen  and  edematous, 
the  scrotal  veins  being  considerably  engorged.  When  the  inflammation  is 
fully  developed,  it  is  rarely  possible  to  differentiate  the  two  portions  of  the 
testicle,  the  swelling  presenting  a  more  or  less  ovoid,  tense,  and  smooth 
tumor,  this  conformation  being  dependent  upon  the  fluid  effusion  already 
alluded  to. 

During  the  flrst  day  or  two  the  pain  increases  and  finally  becomes  very 
severe;  in  three  or  four  days,  however,  it  begins  to  subside,  and  toward  the 
end  of  the  first  week  there  is  very  little  pain,  the  inflammation  having  be- 
come stationary.  Resolution  usually  begins  about  the  seventh  or  eighth  day. 
The  severe  pain  at  the  onset  of  epididymitis  is  explicable,  as  in  acute  orchitis, 
by  inflammatory  swelling  of  sensitive  tissues  surrounded  by  unyielding  and 
dense  fibrous  envelopes.  As  the  inflammation  subsides,  edema  of  the  scrotum 
is  more  pronounced,  the  tissues  perhaps  becoming  quite  flaccid.  Where 
there  is  spermatic  phlebitis  edema  of  both  scrotum  and  penis  is  marked. 

When  the  serous  fluid  in  the  tunica  vaginalis  has  absorbed  to  a  certain 
extent,  it  becomes  possible  to  outline  the  two  anatomic  divisions  of  the  testis, 
and  it  will  be  found  that  the  body  of  the  organ  is  comparatively  little  en- 
larged, while  the  epididymis  presents  an  elongated,  indurated,  and  irregu- 
larly nodular  swelling,  capping  the  body  of  the  organ  above  and  behind. 
Where  the  testis  itself  seems  to  be  considerably  enlarged,  the  apparent  en- 
largement is  due  to  inflammatory  thickening  of  the  tunica  albuginea  and 
the  tunica  vaginalis,  associated  with  the  deposition  of  plastic  lymph  between 
the  two  layers  of  the  latter. 

In  some  cases  the  symptoms  are  not  acute,  but,  on  the  contrary,  the 
inflammation  comes  on  insidiously  and  the  patient  can  move  about  with 
comparatively  little  discomfort.  In  the  acute  form  locomotion  is  so  excru- 
ciatingly painful  that  he  is  usually  compelled  to  rest,  nolens  volens. 

DuRATiGN. — In  favorable  cases  the  disease  lasts  from  two  to  three  weeks. 
Much  depends  upon  the  acuteness  of  the  afl:ection  and  the  conscientiousness 
of  both  surgeon  and  patient.  In  a  general  way,  the  more  rigidly  physical 
and  sexual  rest  and  restricted  diet  are  imposed,  the  shorter  the  duration  of 
the  case. 


958  IXFLAilMATOKY    AFFECTIOXS    OF    THE    TESTIS.      ' 

Peogxosis. — The  prognosis  of  eiDididj-mitis  is  obyiously  fayorable  in 
almost  all  cases.  The  untoward  results  shortly  to  be  described  occur  only 
exceptionally,  save  as  regards  the  effect  of  the  disease  upon  the  procreative 
function.  In  this  respect,  there  is  certainly  considerable  danger  of  per- 
manent injury  in  all  cases.  In  the  majority  of  cases,  even  under  proper 
management,  a  certain  degree  of  induration  of  the  epididymis  remains 
permanently.  This  may  be  diminished  by  appropriate  treatment;  hence 
the  case  should  be  kept  under  observation  for  some  time.  The  induration 
has  been  known  to  disappear  some  years  after  the  occurrence  of  the  inflam- 
mation. A  moderate  amount  of  induration  is  perhaps  compatible  with  per- 
fect functional  capacity  of  the  affected  testis. 

The  possible  results  of  epididymitis  are  numerous  and  varied.  The 
most  important  result  to  be  apprehended  is  obliteration  of  the  lumen  of 
the  convoluted  tube  comprising  the  epididymis  and  beginning  of  the  vas 
deferens,  or,  short  of  complete  obliteration,  a  lessening  of  the  caliber  of  the 
tube,  from  thickening  of  the  mucous  membrane  and  the  pressure  of  pro- 
liferated connective  tissue  in  and  about  the  substance  of  the  vas  deferens, 
sufficient  to  prevent  the  passage  of  the  seminal  elements  from  the  testicle  in 
sufficient  amount  to  fructify  the  ovum.  This  condition  develops  and  be- 
comes permanent  in  a  moderate  proportion  of  cases  of  epididymitis — prob- 
ably in  all  cases  temporarily.  In  some  instances  resolution  is  comparatively 
rapid,  while  in  others  it  may  be  weeks  or  months  before  patency  of  the  vas 
deferens  is  restored.  If  irritation  be  perpetuated  by  sexual  excesses,  mas- 
turbation, venereal  excitement,  intemperance,  or  violent  exercise,  the  process 
becomes  chronic,  with  consequent  loss  of  function  of  the  affected  organ.  In 
these  cases  much  may  be  done  by  judicious  treatment,  even  after  induration 
of  the  epididymis  has  existed  for  a  long  time.  It  is  fortunate  that  atrophy 
of  the  testis  does  not  result  from  simple  obliteration  of  its  afferent  duct.  It 
is  probable  that  for  a  variable  period  after  epididymitis  the  secretory  func- 
tion of  the  testis  is  affected,  with  consequent  diminution  in  quantity  and 
perversion  in  quality  of  the  semen. 

Impotence  does  not  result  from  obliteration  of  the  epididymis  per  se; 
pseudo-impotence  may  result  as  a  consequence  of  the  psychic  effect  of  the 
patient's  consciousness  of  testicular  disease.  Even  when  both  testes  are 
affected  the  patient  still  retains  his  sexual  power.  Erection  and  orgasm  are 
perfect,  and  there  is  a  discharge  of  fluid  resembling  semen  in  every  respect, 
save  in  the  presence  of  spermatozoa. 

Neuralgia  of  the  testis  is  an  occasional  result  of  epididymitis.  A  patient 
at  present  under  the  author's  care  had  epididymitis  about  a  year  ago,  and 
has  since  suffered  more  or  less  constantly  from  severe  testicular  pain  and 
tenderness.  Sexual  excitement  invariably  produces  considerable  pain.  Some 
benefit  has  been  derived  in  this  case  from  the  use  of  electricity  and  a  close- 
fitting  suspensory  bandage. 

Chronic  induration  of  the  epididymis  very  often  bears  a  close  relation 


TEEATMENT    OF    EPIDIDYMITIS.  959 

to  constitutional  syphilis.  The  author  has  noted  that  gonorrheal  epididy- 
mitis in  syphilitics  is  likely  to  be  sIoav  and  chronic,  being  more  marked  and 
enduring  than  in  ordinary  cases.  It  is  occasionally  necessary  in  syphilitics 
with  gonorrheal  epididymitis  to  administer  potassium  iodid  and  mercury 
quite  liberally  in  order  to  induce  resolution. 

Suppuration  rarely  occurs  in  acute  epididymitis,  being  dependent  on 
secondary  infection,  either  by  pus-microbes  or  tubercle  bacilli.  In  strumous 
and  tubercular  subjects  the  disease  is  likely  to  be  subacute  or  chronic,  pos- 
sibly with  chronic  abscess  and  sinuses.  In  some  instances  chronic  abscess 
forms  and  leads  to  pseudotubereular  or  even  true  tubercular  disease.  Many 
cases  of  so-called  tubercular  testis  are  really  instances  of  chronic  suppura- 
tive epididymitis. 

Chronic  hydrocele  occasionally  results  from  acute  epididymitis.  Ziessl 
claims  that  it  is  the  most  frequent  result.  It  usually,  however,  follows  sub- 
acute inflammation  resulting  from  traumatism.  The  author  believes  that 
hydrocele  is  due  to  some  slight  injury  of  the  testis  in  a  large  proportion  of 
cases.  The  traumatism  is  followed  by  a  low  grade  of  inflammation,  asso- 
ciated with  irritation  of  and  hypersecretion  by  the  tunica  vaginalis.  In 
many  cases  this  condition  of  chronic  inflammation  of  the  epididymis  escapes 
detection  until  the  attendant  effusion  has  assumed  so  great  a  size  that  the 
patient  cannot  fail  to  perceive  it.  Injury  of  the  epididymis  is  especially 
liable  to  be  followed  by  hydrocele  at  a  period  more  or  less  remote. 

Sloughing  of  the  testis  does  not  occur  from  simple  epididymitis.  It  is 
to  be  apprehended,  however,  in  those  exceptional  cases  in  which  inflamma- 
tion of  the  epididymis  is  accompanied  by  true  orchitis. 

Cancer  of  the  testis  has  been  said  to  result  from  epididymitis,  but  the 
evidence  so  far  advanced  is  inconclusive.  It  is  logical  to  infer,  however,  that, 
in  the  presence  of  a  predisposition  to  cancer,  epididymitis — especially  the 
traumatic  form — may  develop  it  quite  as  readily  as  irritation  from  other 
causes. 

Treatment. — The  primary  consideration  is  prophylaxis.  Patients 
with  acute  gonorrhea  should  be  instructed  to  keep  as  quiet  as  possible; 
if  the  urethritis  be  very  severe,  perfect  rest  should  be  enjoined.  When- 
ever, in  the  course  of  urethritis,  the  testis  becomes  tender  and  painful  or 
the  patient  experiences  painful  sensations  in  the  groin,  complete  rest  in  bed 
is  advisable.  A  nicely-adjusted  suspensory  bandage  is  a  wise  precaution  in 
all  cases  of  severe  gonorrhea.  All  manipulations  of  the  urethra  in  the  treat- 
ment of  chronic  urethritis,  organic  stricture,  and  prostatic  disease  should  be 
as  gentle  as  possible.  Sexual  excitement  and  alcoholics  should  be  strictly 
avoided. 

Experience  shows  that  antiphlogistic  measures  are  a  most  important  in- 
dication in  acute  epididymitis.  Milton,  however,  enters  into  a  very  specious 
argument  against  the  advantages  of  the  antiphlogistic  method.    He  says: — 


960  IXFLAMMATOKY    AFFECTIOXS    OF    THE    TESTIS. 

The  recommendation  to  use  antiphlogistic  means  is  only  consistent  with  the 
theory  of  those  who  consider  that  inflammation  is  not  to  be  exorcised  but  by 
measures  which  reduce  the  patienfs  health;  they  who  hold  such  a  view  ought  to 
stand  by  the  axiom  that  we  can  only  banish  the  intrusive  demon  secundum  artem. 
But  I  am  inclined  to  suspect  that  the  system  now  lives  only  by  sufferance,  and 
that  no  one  of  its-  supporters,  if  put  to  the  test,  could  prove  it  to  be  called  for. 
Bleeding,  considered  by  M.  Robert  to  be  indispensable  when  the  body  of  the  testicle 
is  affected,  owes  its  t€nure  of  existence — if,  indeed,  it  exists  at  all — to  a  long  and 
most  respectable  descent — to  ancestral  prestige,  in  fact;  but  I  suppose  we  may  look 
upon  it  as  gone  for  good,  whatever  the  affection  of  the  organ  may  seem  to  call  for. 
Leeches,  calomel,  antimony,  salines,  etc.,  often  leave  the  pain  unrelieved  for  eight 
or  ten  days;  so  long  as  this  lasts  the  inflammation  is  not  subdued,  still  less  can 
we  assume  that  it  is  even  quelled  by  these  means,  seeing  that  if  the  patient  remain 
in  bed  and  restrict  himself  in  respect  to  diet  he  would  cure  himself  just  as  quickly. 
Leeches,  indeed,  can  only  (Uminish  to  a  fractional  extent  the  quantity  of  Wood 
driven  to  any  inflamed  part;  tchereas  the  object  of  the  surgeon  should  he  not  to 
abstract  blood,  but  to  check  the  action  which  impels  it  in  an  abnormal  direction. 
The  condition  of  this  fluid  offers  a  check  to  the  process;  by  relieving  this  rest  we 
set  it  going  again,  pleno  rivo.  My  experience  of  tartar  emetic,  calomel,  and  other 
items  of  antiphlogistic  treatment  is  not  favorable,  or,  in  plain  terms,  I  believe 
them  to  be  perfectly  useless. 

Milton's  meaning  is  somewhat  obscured  by  the  luxuriance  of  his  verbi- 
age, but  it  is  plain  to  be  seen  that  he  entertains  a  deep-seated  prejudice 
against  any  and  all  measures  of  local  depletion  and  antiphlogistic  remedies. 
Scarification  of  the  scrotal  veins  and  Vidal's  puncture  of  the  tunica  vaginalis 
are  also  relegated  by  this  author  to  the  dead-lumber  room.  In  spite  of  the 
illustrative  cases  offered  by  Mr.  Milton, — which  are  certainly  very  meager 
as  contrasted  with  the  large  number  of  cases  upon  which  the  general  opinion 
of  the  profession  regarding  antiphlogistic  measures  is  based, — the  author  is 
inclined  to  think  that  Milton's  opinion  is  the  result  of  primary  prejudice 
rather  than  careful  observation  of  the  effects  of  the  remedies  he  so  em- 
phatically condemns. 

Much  depends  upon  the  period  at  which  antiphlogistic  measures  are 
employed.  When  the  testicle  is  swelling  rapidly,  the  inflammation  being 
but  a  few  hours  old,  it  is  usually  unwise  to  apply  leeches  to  the  inflamed  part. 
They  are  likely  to  increase  irritation  and  enhance  the  determination  of  blood 
to  the  part.  "When,  however,  the  inflammation  is  at  its  height,  stasis  has 
occurred,  the  veins  are  engorged,  and  the  condition  is  chiefly  passive  hyper- 
emia, the  pain  is  perpetuated  by  the  pressure  of  the  blood  which  vasomotor 
p'aresis  prevents  from  getting  out  of  the  part.  The  results  to  be  expected 
from  the  application  of  leeches  or  other  means  of  local  depletion  are  now 
widely  different.  There  is  no  longer  an  active  determination  of  blood  to 
the  part,  but  a  local  engorgement  of  the  tissues  with  blood.  The  application 
of  leeches  at  this  time  is  not  only  beneflcial,  but  in  many  cases  has  a  really 
wonderful  effect  in  relieving  the  agonizing  pain  and  reducing  the  swelling. 

Patients  who  have  had  leeches  freely  applied  at  the  proper  period  of 
the  inflammation  of  the  testis  would  be  considerably  amused  by  Milton's 


TEEATMEXT    OF    EPIDIDYMITIS.  961 

opinion  regarding  their  efficacy.  The  autlior  recalls  the  case  of  a  profes- 
sional gentleman  suffering  from  a  very  acute  epididymitis  who  was  so  quickly 
relieved  by  the  application  of  half  a  dozen  vigorous  leeches  that  he  found 
fault  because  they  had  not  been  applied  earlier.  The  author  unhesitatingly 
recommends  the  proper  application  of  leeches  as  one  of  the  best  measures 
available  for  the  treatment  of  acute  epididj^mitis.  The  average  duration  of 
the  disease  is  not  materially  shortened  by  this  method  of  treatment,  for  the 
cases  requiring  leeches  are  relatively  few,  but  that  they  are  very  beneficial 
will  be  attested  by  the  majority  of  surgeons  who  have  used  them. 

It  is  obvious  that  the  careless  use  of  the  knife  in  scarifying  the  scrotal 
veins  may  lead  to  serious  consequences.  A  patient  is  said  to  have  died  from 
the  opening  of  a  vein  in  the  scrotum.^  This,  however,  was  prior  to  the  in- 
troduction of  our  modern  methods  of  aseptic  and  antiseptic  surgery. 

There  is  one  caution  to  be  imposed  in  regard  to  the  application  of 
leeches  to  the  scrotum;  there  is,  perhaps,  a  greater  tendency  to  excessive 
bleeding  from  the  bites  than  in  any  other  situation.  This  is  explicable  by 
the  looseness  and  vascularity  of  the  tissues  and  the  extreme  warmth  of  the 
part.  The  surgeon  should  be  certain,  therefore,  that  bleeding  from  the 
leech-bites  has  entirely  ceased  before  leaving  his  patient.  Danger  may  be 
obviated  by  touching  each  point  with  a  stick  of  nitrate  of  silver,  after  a  suf- 
ficent  amount  of  depletion  has  been  secured. 

In  cases  in  which  acute  hydrocele  predominates,  the  excruciating  pain 
may  be  quickly  relieved  by  puncture  of  the  distended  tunica  vaginalis,  as 
originally  recommended  by  Vidal.  This  operation  should  be  performed  sub- 
cutaneously  with  a  very  small  tenotome.  A  single  straight  incision  may  be 
made  in  the  serous  membrane,  or  a  number  of  small  subcutaneous  punctures 
made  at  different  points.  A  greater  or  less  quantity  of  serum  is  thus  allowed 
to  escape  into  the  subcutaneous  areolar  tissue.  Eelief  from  pain  is  in- 
stantaneous. It  appears  to  be  unnecessar}^  to  evacuate  a  large  quantity  of 
fluid,  relief  of  the  extreme  tension  being  the  only  requisite.  The  author's 
experience  has  apparently  shown  that  this  method  shortens  the  duration  of 
the  disease.  Care  should  be  taken  to  avoid  cutting  into  the  body  of  the 
testis.  Where  orchitis  also  exists,  however,  deliberate  incision  of  the  tunica 
albuginea  may  be  necessary.  Aspiration  by  the  hypodermic  syringe  is  often 
efficacious. 

The  application  of  pounded  ice  by  means  of  a  rubber  bag  or  ordinary 
bladder  was  long  ago  recommended  by  that  pioneer  in  the  study  of  diseases 
of  the  testis,  Curling,  and  is  in  favor  with  many  surgeons  at  the  present 
time.  The  author  considers  this  method  inferior  to  the  application  of  moist 
heat.  It  is  certainly  uncomfortable,  and,  like  many  other  inconvenient 
methods  of  treatment,  is  not  likely  to  be  carried  out  faithfully  by  the  pa- 
tient.    One  has  but  to  apply  a  bladder  of  ice  for  a  short  time  to  his  own 


^Johnson.     Quoted  by  Milton:     "Gonorrhea  and  Spermatorrhea. 


962  INFLAMMATOET   AFFECTIONS    OF    THE    TESTIS. 

healthy  testes  to  be  convinced  of  the  disagreeable  character  of  the  treatment. 
When  applied  to  an  acutely  inflamed  organ  it  produces,  on  the  average,  con- 
siderable discomfort.  These  remarks  are  not  intended  to  convey  the  idea 
that  applications  of  ice  should  never  be  used,  for  should  the  application  of 
moist  heat  prove  impracticable  or  ineffectual,  it  is  well  to  try  the  ice  appli- 
cations. 

Numerous  methods  of  treatment  by  counter-irritation  have  been  sug- 
gested, but  most  of  them  are  only  to  be  remembered  as  a  matter  of  curiosity, 
and  cannot  be  too  strongly  condemned.  The  scrotum  is  very  sensitive  and 
resents  irritating  applications.  Applications  '  of  iodin  have  been  recom- 
mended, but,  so  far  as  acute  inflammation  of  the  testicle  is  concerned,  this 
method  is  unwise.  In  subacute  and  chronic  inflammations,  however,  ap- 
plications of  mild  solutions  of  iodin  or  the  compound  iodin  ointment  are 
often  beneficial.  Strong  applications  of  nitrate  of  silver  have  been  suggested 
by  Furneaux  Jordan.    They  are  not  only  painful,  but  useless. 

Pressure  has  been  recommended  in  the  acute  stage  of  epididymitis,  but 
the  method  is  so  illogical,  dangerous,  and  obviously  painful,  that  it  is  hardly 
necessary  to  comment  upon  it. 

Milton  enumerates  in  his  exhaustive  treatise  nineteen  different  meth- 
ods of  treatment  for  epididymitis,  this  number  by  no  means  including  all 
of  the  various  systems.  Like  many  other  diseases  for  which  a  large  number 
of  widely  different  methods  of  treatment  have  been  recommended,  epididy- 
mitis has  within  certain  limits  a  natural  course,  resembling  in  this  respect 
its  parent,  gonorrhea.  Wlienever  a  large  number  of  remedies  are  recom- 
mended for  any  particular  disease  by  surgeons  of  equal  eminence  and  ex- 
perience, it  is  safe  to  conclude  that  no  measure  of  treatment  is  effectual  in 
aborting  the  disease,  and  that  it  really  has  a  natural  course  which  cannot  be 
greatly  modified  by  treatment.  Eational  therapy,  however,  will  shorten  the 
average  duration  of  epididymitis;  that  any  method  of  treatment  will  abort 
the  disease  the  author  does  not  believe. 

The  most  useful  routine  measure  in  epididymitis  is  the  application  of 
moist  heat  in  combination  with  narcotic  drugs.  The  application  that  most 
satisfactorily  meets  the  indications  is  the  tobacco-and-linseed  poultice.  This 
is  prepared  of  equal  parts  of  fine-cut  tobacco  and  linseedmeal,  and  applied  as 
hot  as  can  be  tolerated.  The  poultice-mass  should  be  spread  in  liberal  quan- 
tity upon  stout  muslin,  and  covered  with  a  layer  of  thin  cheese-cloth  to  pre- 
vent its  adhering  to  the  skin.  The  narcotic  effect  of  the  poultice  may  be 
enhanced  by  sprinkling  it  freely  with  laudanum.  In  lieu  of  the  tobacco 
poultice,  linseed  and  laudanum  alone  may  be  used.  The  poultices  should 
be  changed,  on  the  average,  every  hour  or  hour  and  a  half.  By  covering 
them  with  oiled  silk  and  cotton  batting  the  heat  may  be  retained  longer, 
•but,  as  a  rule,  it  is  injurious  to  leave  the  poultices  in  contact  with  the  part 
more  than  two  hours  without  changing.  An  excellent  plan  is  to  have  a 
number  of  poultices  prepared,  keeping  them-  hot  in  an  ordinary  bread- 


TEEATMEXT    OF    EPIDIDYMITIS.  963 

steamer.  The  testes  should  be  supported  by  a  small  pillow  or  wad  of  cot- 
ton or  lambs'  wool,  placed  between  the  thighs.  Care  should  be  taken  not 
to  bolster  up  the  testicle  too  high  upon  the  pubes,  else  the  cord  will  be  bent 
upon  itself,  and  if  the  latter  be  much  inflamed  this  kinking  may  cause  con- 
siderable subsequent  annoyance. 

It  was  formerly  thought  that  restoration  of  gonorrheal  discharge  by  irri- 
tant injections  cured  epididymitis.  This  notion,  however,  was  founded  upon 
erroneous  ideas  of  the  pathology  of  the  disease  and  the  treatment  of  in- 
flammation in  general,  being  based  upon  an  old  quasiveterinary  idea  of  the 
benefits  of  "issues":  an  ancient  theory  that  was  responsible  for  much  dis- 
comfort to  surgical  patients. 

Mr.  Milton's  remarks  upon  the  question  of  cessation  of  urethral  dis- 
charge in  acute  epididymitis  are  interesting  as  well  as  surprising: — 

I  can  safely  say  that  I  never  saw  an  unequivocal  instance  of  gonorrhea  arrested 
by  swelled  testicle  coming  on.  If  any  of  my  readers  appeal  to  authority,  and  say 
that  in  a  simple  matter  of  fact  like  this  it  is  impossible  that  so  many  excellent  ob- 
servers— numbering  among  them  Brodie,  Swediaur,  Cooper,  Larrey,  Wallace,  and 
many  others — could  deceive  themselves,  I  meet  the  objection,  first,  by  asking  them 
to  use  their  own  eyes  and  ears  and,  secondly,  by  referring  them  to  Curling,  Fournier, 
and  Ricord,  who,  basing  their  conclusions  on  an  immense  number  of  cases,  have  de- 
cided against  the  old  doctrine. 

Inasmuch  as  the  number  of  authorities  upon  the  one  hand  is  compen- 
sated for  by  the  eminence  of  the  authorities  upon  the  other,  the  author  can 
only  follow  Milton's  suggestion  in  regard  to  using  his  own  eyes  and  ears. 
In  his  experience  it  is  exceptional  that  the  discharge  does  not  cease  or  greatly 
diminish  with  the  onset  of  acute  epididymitis.  Should  the  patient  not  con- 
sult the  surgeon  before  the  inflammation  of  the  testis  has  begun  to  subside, 
he  usually  states  that  his  discharge  is  just  returning.  Indeed,  recurrence  of 
discharge  is  heralded  in  the  popular  mind  as  an  indication  of  improvement 
of  the  condition  of  the  testis.  In  the  majority  of  cases  the  discharge  either 
ceases  or  diminishes  greatly  with  the  onset  of  the  inflammation,  and  returns 
as  the  inflammation  resolves.  The  recurrent  discharge  is  rarely  so  profuse 
as  before  the  epididymitis  developed,  not  because  of  any  beneficial  effects 
of  the  latter  upon  the  urethral  inflammation,  but  because  of  the  prolonged 
rest  necessitated  by  the  inflammation  of  the  epidid3'mis  and  the  more  ad- 
vanced period  of  the  urethritis. 

The  opinion  of  Eicord  is  literally  as  follows: — 

It  deserves  to  be  noted,  as  the  contrary  opinion  generally  prevails,  that  the  dis- 
charge, which  is  often  much  diminished  during  the  course  of  an  epididymitis,  never 
entirely  ceases,  or,  at  least,  this  does  not  occur  more  than  once  in  two  hundred  cases. 
The  more  abundant  return  of  the  discharge  follows  a  decrease  of  the  intensity  of  the 
inflammation  of  the  epididymis,  but  the  artificial  inci'ease  of  the  discharge  during 
the  acute  stage  of  epididymitis  either  does  not  influence  this  disease  or  else  aggra- 
vates it. 

It  will  be  observed  that  Eicord  acknowledges  the  marked  diminution 


964 


INFLAMMATOEY    AFFECTIOXS    OF    THE    TESTIS. 


of  urethral  discharge  in  infia-mmation  of  the  testicle,  but  states  that  it  does 
not  cease  entirely  more  than  once  in  two  hundred  eases.  He  also  notes  its 
recurrence  as  the  inflammation  of  the  epididymis  begins  to  subside.  Mr. 
Milton  evidently  misinterprets  M.  Eicord. 

After  the  acute  symptoms  have  subsided,  judiciously  applied  pressure 
by  means  of  strapping  with  adhesive  plaster  is  very  useful,  often  abbreviating 
the  duration  of  the  disease  considerably.  So  soon  as  the  testis  can  be 
handled  without  producing  much  pain,  the  adhesive  straps  should  be  ap- 
plied. The  mole-skin  diachylon-plaster  will  be  found  preferable  to  any 
other  form.  Eubber  plaster  may  be  used,  but  is  less  cleanly.  The  hair 
should  first  be  removed  from  the  scrotum  and  inguinal  region  and  the  parts 


Fig.  219. — Strapping  the  testis. 


carefully  washed  and  dried.  The  testis  should  now  be  grasped  at  its  base 
by  the  thumb  and  finger,  thus  forming  a  pear-shaped  tumor;  around  the 
neck  of  this  tumor — represented  by  the  spermatic  cord — a  strip  of  ordinary 
roller  bandage,  about  three-fourths  of  an  inch  in  width,  should  be  wrapped, 
a  small  strip  of  adhesive  plaster  being  wound  about  this  to  hold  it  in  place. 
The  testis  is  now  isolated  and  ready  for  the  straps.  Four  or  five  straps,  about 
three-fourths  of  an  inch  in  width,  should  now  be  applied  over  the  organ  from 
one  side  of  its  base  to  the  other;  then,  beginning  at  the  top,  narrow  strips 
of  about  half  an  inch  in  width  should  be  wound  round  and  round  in  a  basket- 
like form  until  the  testis  is  completely  covered.  Small  straps  are  then  in- 
terlaced over  the  bottom  of  the  tumor  and  the  whole  pressed  for  a  moment 
in  the  hand  to  be  certain  that  the  plaster  has  adhered.    In  performing  this 


TKEATMENT    OF    EPIDIDYMITIS.  965 

oiDeration  it  is  best  to  have  the  patient  upon  his  back  to  gain  the  benefit  of 
gravity  in  depleting  the  testicle.  Before  the  operation  is  completed,  no 
matter  how  carefully  the  straps  may  have  been  applied,  it  will  be  found  that 
the  envelopment  of  plaster  is  already  too  large  for  the  contained  tumor  and 
will  crumple  under  the  fingers.  After  remaining  awhile  in  the  recumbent 
posture  the  patient  can  usually  apply  a  suspensory  bandage  and  go  about 
his  business,  providing  he  does  not  exercise  too  actively.  x\t  the  end  of 
twenty-four  to  thirty-six  hours  the  strapping  should  be  removed  and  reap- 
plied.   As  a  rule,  not  more  than  two  or  three  strappings  are  necessary. 

Mr.  Milton  evidently  does  not  favor  the  method  of  treatment  just  de- 
scribed.   He  comments  upon  it  as  follows: — 

Strapping  the  testicle  is  now,  I  fancy,  rather  a  matter  of  tradition  than  of  actual 
practice,  and  any  notice  of  it,  therefore,  is  more  the  offspring  of  a  desire  to  make  the 
author's  work  complete  than  a  practical  exposition  of  the  benefits  observed  to  follow 
from  the  operation.  I  certainly  think  surgery  will  not  suffer  much  from  its  falling 
into  desuetude.  It  is  dirty,  painful,  and,  generally  speaking,  uncalled  for;  and  as 
gangrene  has  been  known — though  I  admit  very  rarely — to  follow  the  employment 
of  it,  the  inconveniences  of  the  practice  must,  in  my  judgment,  be  held  to  outweigh 
the  advantages. 

It  is  hardly  probable  that  Milton  has  had  much  practical  experience 
with  strapping  the  testis.  There  is  certainly,  when  properly  performed, 
nothing  ""'filthy''  about  the  application  of  the  adhesive  straps,  and  the 
opinion  that  it  is  not  beneficial  and  uncalled  for  certainly  could  not  emanate 
from  one  who  had  given  the  method  a  fair  and  impartial  trial.  Patients 
who  have  been  subjected  to  the  method  are  impressed  very  favorably  by 
its  results.  If  the  method  be  properly  used,  very  few  patients  will  be  un- 
willing to  submit  to  it  again,  should  the  necessity  arise.  Strapping  is 
especially  beneficial  in  subacute  cases  in  which  there  is  considerable  inflam- 
matory exudate,  with  resulting  inconvenience  in  locomotion.  Caution  is, 
of  course,  necessary  in  the  application  of  the  method,  in  view  of  the  fact  that 
gangrene  has  occurred  from  it,  no  matter  how  rarely.  The  principal  diffi- 
culty in  strapping  is  the  rapidity  with  which  the  dressing  becomes  loosened 
by  speedy  diminution  of  the  swelling.  Caution  should  be  observed  re- 
garding the  period  at  which  the  straps  are  applied,  for,  if  done  too  soon, 
when  the  inflammation  is  at  its  height,  severe  pain,  and  perhaps  gangrene 
may  result.  The  rare  occurrence  of  gangrene  should  not  deter  the  surgeon 
from  using  the  method,  for  even  though  gangrene  has  occurred  where  it 
has  been  used,  it  remains  to  be  proved  whether  it  was  the  direct  result  of 
the  strapping  or,  what  is  more  likely,  the  inevitable  consequence  of  coin- 
cident orchitis,  which,  as  is  well  known,  occasionally  results  in  gangrene. 

Whether  strapping  be  used  or  not,  a  close-fitting  suspensory  should  be 
applied  as  soon  as  the  patient  is  able  to  get  about. 

Local  applications  of  various  drugs  are  serviceable  in  the  various  stages 


966  IXFLAMMATOKY    AFFECTIOXS    OF    THE    TESTIS. 

of  epididymitis.     In  the  acute  stage  the  author  has  had  the  best  results 
from  the  following: — 

IJ  Ext.  belladon gr.  x. 

Ext.  aconiti  rad gr.  x. 

Morpli.  sulph gr.  xx. 

Mentholis    gr.  xxx. 

Lanolin   3j. — M. 

This  should  be  aj^plied  on  a  piece  of  lint  large  enough  to  envelop  both 
testes,  and  changed  twice  a  day.  Mercurial  ointments  may  prove  of  service 
at  any  stage  of  the  disease.  The  blue  ointment  or  a  mild  oleate  may  be  ap- 
plied, either  alone  or  in  combination  with  poultices.  After  the  acute  in- 
flammatory symptoms  have  subsided  iodin  and  mercurial  ointments  are  espe- 
cially serviceable.  These  applications  are  quite  useful  where,  for  any  reason, 
strapping  is  inadmissible  and  when  resolution  of  the  swelling  is  slow.  One 
of  the  best  applications  in  acute  epididymitis  is  ichthyol  in  25-per-cent. 
solution  combined  with  belladonna. 

Electricity  is  the  best  remedy  at  our  command  for  the  reduction  of  the 
testicular  swelling  after  the  acute  symptoms  have  subsided.  If  properly 
used,  this  remedy  will  accomplish  much  in  promoting  resolution.  When 
the  inflammation  subsides  sufficiently  to  permit  the  testis  to  be  handled  with 
more  or  less  impunity,  the  negative  pole  of  the  faradic  battery  will  stimulate 
absorption,  and  thus  promote  resolution  of  the  inflammation.  The  electric- 
ity should  be  combined  with  massage. 

The  author  recalls  the  case  of  a  gentleman  who  had  suffered  great  pain 
in  the  inguinal  region  as  a  consequence  of  extreme  swelling  and  strangula- 
tion of  the  spermatic  cord  incidental  to  acute  epididymitis.  Agonizing  pain 
was  experienced  along  the  course  of  the  cord  for  some  time  after  the  pain 
in  the  testis  had  disappeared.  This  condition  was  resistant  to  ordinary 
measures  of  treatment.  The  faradic  current  was  applied  to  the  cord,  and 
the  pain  was  speedily  relieved.  Should  stimulating  applications  of  elec- 
tricity be  made  too  early  in  the  case,  however,  all  the  symptoms  will  be 
aggravated. 

Internal  remedies  are  of  considerable  service  in  epididymitis.  First  and 
foremost  come  the  narcotic  drugs,  of  which  opium  is  the  type.  Morphia  may 
be  given  either  by  the  mouth  or  subcutaneously,  and  in  all  cases  a  sufficient 
quantity  should  be  administered  to  relieve  pain.  This  necessarily  varies  with 
the  circumstances  of  the  case.  Opium  has  the  same  beneficial  effect  in  this 
form  of  inflammation  as  in  others,  having  not  only  its  peculiar  specific  effect 
in  relieving  pain,  but  also  the  property  of  directly  antagonizing  the  inflam- 
mation. As  is  well  known,  this  drug  is  almost  a  speciflc  for  serous  inflam- 
mations of  various  kinds,  and  inasmuch  as  the  most  painful  element  of 
swelled  testis  is  inflammation  of,  and  effusion  of  serous  fluid  into,  the  tunica 
vaginalis,  opiates  are  a  prime  indication.  Codein  is  often  preferable  to 
morphia.     Aconite,  veratrum  viride,  and  the  coal-tar  series  may  be  useful 


TEEATMENT    OF    EPIDIDYMITIS.  967 

in  the  acute  stage,  especially  if  the  fever  run  high.  Bromid  of  potassium, 
gelsemium,  camphor,  lupulin,  and  other  sedative  and  anaphrodisiac  prepa- 
rations may  be  called  for  in  the  course  of  the  case. 

Stimulating  drugs  shouM  not  be  given  in  epididymitis,  and  if  balsams 
have  been  prescribed  they  should  be  stopped  as  soon  as  testicular  inflam- 
mation is  evident.  In  short,  all  treatment  for  the  gonorrhea,  and  particu- 
larly injections  and  balsamic  preparations,  should  be  laid  aside  as  soon  as 
inflammation  of  the  testis  develops. 

Pulsatilla  has  been  recommended  very  highly  in  inflammation  of  the 
testis.  The  use  of  this  drug  has  been  chiefly  confined  to  homeopathic  prac- 
tice, but  attention  has  been  called  tO'  its  efficacy,  particularly  in  inflamma- 
tory affections  of  the  testis,  by  several  prominent  members  of  the  regular 
profession,  Piffard  having  especially  commended  it. 

From  the  clinical  study  of  the  action  of  pulsatilla  the  author  has  con- 
cluded that  it  is  of  considerable  value.  The  drug  has  received  less  attention 
than  it  deserves  from  the  regular  jDrofession  because  of  its  having  been  con- 
sidered a  homeopathic  preparation,  this  neglect,  by  the  way,  being  decidedly 
unworthy  of  "regular"  liberality.  As  given  by  the  homeopaths  in  infinites- 
imal doses,  it  is  obviously  impossible  to  obtain  its  physiologic  effects,  and  it 
is  impracticable  to  determine  whether  any  apparent  benefit  is  due  to  the 
drug  or  constitutes  the  natural  course  of  the  disease.  The  author  is  not 
aware  that  any  explanation  of  the  action  of  pulsatilla  is  given  by  homeo- 
pathic writers,  who  speak  vaguely  of  its  specific  effect  upon  the  mucous 
membranes,  the  female  generative  organs,  and  the  cerebro-spinal  axis.  It 
is  probable,  however,  that  its  effects  are  due  to  its  influence  upon  the  nervous 
system — possibly  associated  with  a  direct  effect  upon  glandular  structures. 
The  drug  apparently  has  a  special  action  upon  the  testis  itself,  as  evi- 
denced by  speedy  relief  of  pain  and  tenderness.  It  has,  on  the  other  hand, 
no  effect  upon  the  induration  of  the  inflamed  organ,  and  does  not  appre- 
ciably diminish  serous  effusion.  The  benefit  of  pulsatilla  in  gonorrheal  epi- 
didymitis may  possibly  be  due  in  slight  measure  to  its  action  upon  the  in- 
flamed urethra,  particularly  the  deeper  portions.  Pulsatilla  should  be  given 
in  doses  of  10  minims  of  the  tincture  every  two  or  three  hours. 

Saline  and  mercurial  cathartics  are  of  especial  advantage  at  the  onset 
of  epididymitis.  Mercury  is  also  useful  for  its  antiphlogistic  effect.  It  is 
particularly  apt  to  be  serviceable,  if,  as  is  frequently  the  case,  the  patient 
is  of  syphilitic  constitution.  The  treatment  of  inflammations  by  calomel 
and  opium  is  extremely  old  fashioned,  but  has  long  been  the  main  reliance 
of  English  surgeons.  Mercury  certainly  has  the  power  of  limiting  and  pro- 
moting the  absorption  of  inflammatory  exudate,  and,  combined  with  potas- 
sium iodid  in  the  latter  stages  of  epididymitis,  it  has  a  decided  effect  in  pro- 
moting resolution.  In  chronic  thickening  of  the  epididymis,  particularly 
where  both  sides  are  involved,  the  prolonged  use  of  potassium  iodid  and  mer- 
cury, in  combination  with  electricity,  affords  some  hope  of  success,  even  in 


968  IXFLAMMATOEY   AFFECTI0X3    OF    THE    TESTIS. 

cases  of  long  standing.  Inasmiicli  as  the  induration  often  tends  to  disap- 
pear after  having  lasted  for  a  number  of  months,  we  should  never  despair 
of  a  cure  until  these  remedies  have  been  thoroughly  tried.  This  is  very 
important  as  bearing  u^Don  the  procreative  power  of  the  patient,  particularly 
where  both  testes- are  involved. 

Eelapsing  epididymitis  usually  demands  treatment  for  the  chronic 
urethral,  bladder,  semino-vesicular,  or  prostatic  infection  upon  which  it 
depends. 

Abscesses  of  the  epididj^mis  demand  the  same  treatment  as  suppura- 
tion of  the  bodv  of  the  testis. 


CHAPTEE  XLII. 

NEOPLASMS  OF  THE  TESTIS. 

Syphilis,  Simple  Ixduratiox,  Tuberculosis,  Carcixoma,  Sarco^ia, 

AXD  THE  EaRER  FoRMS  OF  BeXIGN  TuMOR.      CaSTRATIOX. 

The  various  new  growths  of  the  testis  have  been  designated  in  times 
past  by  the  generic  term  "sarcocele."  This  old-fashioned  and  fallacious 
nomenclature  is  still  in  use,  being  applied  by  some  surgeons  to  all  smooth 
and  uniform  enlargements  of  the  organ.  Inasmuch  as  the  term  really  sig- 
nifies nothing,  from  a  scientific  stand-point,  and  is  a  source  of  considerable 
confusion,  it  has  justly  been  relegated  to  the  dead-lumber  room  by  all 
authorities  of  scientific  pretensions. 

syphilitic  xeoplasms  of  the  testis. 

Syphilitic  new  growths  is  the  form  most  often  affecting  the  testis,  and 
includes  a  majority  of  the  cases  that  were  formerly  diagnosed  as  chronic 
inflammation,  simple  hypertrophy,  etc.  So  frequent  are  the  syphilitic  af- 
fections of  the  organ  that  conservative  authorities  have  formulated  the  rule 
that  all  cases  of  chronic  enlargement  of  the  testis  not  proved  to  be  cancer, 
tubercle,  or  the  result  of  preceding  acute  inflammation  are  syphilitic.  This 
rule  may  be  somewhat  exaggerated,  but  it  is  nevertheless  a  pretty  safe  one 
for  guidance  in  diagnosis.  Syphilitic  deposit  may  affect  either  the  epididy- 
mis or  body  of  the  testis  alone  or,  as  is  most  often  the  case,  both  simul- 
taneously, the  process  being,  however,  most  marked  in  the  body  of  the  organ. 
The  disease  appears  in  two  forms,  viz.:  diffuse  and  circumscribed  syphiloma. 

Syphiloma  of  the  EpiDiDYiiis.— Epididymal  syphilis  is  not  frequent, 
and  its  existence  was  not  recognized  until  recent  years,  all  passive  enlarge- 
ments having  been  supposed  to  be  the  result  of  chronic  inflammation.  The 
disease  usually  develops  early  in  the  secondary  period,  and  presents  two 
fairly  well  defined  varieties,  viz.:  yiodular  and  diffuse.  As  a  rule,  however, 
the  process  is  diffuse.  The  diagnosis  is  not  always  easy,  for  a  physically 
similar  condition  often  results  from  chronic  inflammation,  and  may  even  be 
beneficially  affected  by  treatment  with  mercury  and  iodin — the  supposedly 
crucial  test.  The  tumor  is  comparatively  painless  and  not  especially  tender 
or  sensitive  to  pressure.  Suppuration  never  occurs  and  recovery  is  rapid 
under  proper  management.  All  subacute  and  chronic  enlargements  of  the 
epididymis  should  receive  antisyphilitic  treatment,  whether  syphilis  is  an 
indubitable  factor  in  the  history  or  not;  rapid  disappearance  under  mer- 
cury and  iodin  is  prima  facie  evidence  of  the  existence  of  that  disease;  but 
it  is  to  be  remembered  that  inflammatory  enlargements  will  often  slowly 
yield  to  the  same  remedies. 

(969) 


970  XEOPLASIIS    OF    THE    TESTIS. 

Stphilo^iia  of  the  Body  of  the  Testis.  —  Syphiloma  of  tlie  testis 
proper  is  quite  frequent,  being  ordinarily  known  under  the  name  syphilitic 
orchitis,  a  term  as  inaccurate  as  it  is  misleading  and  ancient.  The  affection  is 
met  with  in  two  forms,  viz.:  (a)  diffuse,  interstitial  gummy,  or  syphilomatous 
infiltration,  and  (&)  localized  gummy  deposit,  the  latter,  however,  being  often 
ingrafted  upon  the  former,  constituting,  in  fact,  a  localization  of  the  gen- 
eral cell-deposit. 

Diffuse  Infiltration. — The  diffuse  form  has  been  likened  to  diffuse 
hepatitis,  nephritis,  etc.,  and  is  designated  by  some  writers  as  interstitial 
orchitis,  involving  the  parenchyma  and  fibrous  envelope  of  the  organ;  thus, 
Eicord  termed  the  affection  "albuginitis."'"  A  careful  review  of  the  pathology 
of  syphilis  will  demonstrate  that  it  is  not  an  inflammation  in  the  true  sense 
of  the  term,  unless  all  of  the  neoplasmata  of  syphilis  may  properly  be  so 
styled,  which  is  not  the  case.  The  rationale  of  the  formation  ^f  syphiloma  of 
the  testis  in  late  syphilis,  or  of  syphilitic  testis  occurring  early  in  the  course 
of  syphilis,  is  probably  as  follows:  In  the  early  cases,  as  a  consequence  of  pre- 
existing epididymitis,  orchitis,  or  chronic  irritation  resulting  from  injury, 
a  localized  cell-proliferation  of  leucocytes  and  lymph-cells — i.e.,  syphilized 
cells, — occurs  in  the  parenchyma  and  superficies  of  the  testis.  The  connec- 
tive-tissue cell,  being  a  derivative  of  the  leucocyte, — for  which  cell  the  syph- 
ilitic infection  has  a  special  predilection, — partakes  of  the  same  influence 
that  the  disease  exerts  upon  the  parent-cell, — viz.:  an  abnormal  propensity 
for  proliferation, — as  a  consequence  of  which  the  connective-tissue  stroma 
and  envelope  of  the  testis  become  hyperplasic  and  thickened.  There  is, 
however,  this  difference  between  the  cells  derived  from  proliferation  of 
syphilized  connective-tissue  cells  and  those  derived  from  leucocytes  and 
lymph-cells,  viz.:  the  former  do  not  tend  to  undergo  fatty  degeneration 
and  resolution  so  markedly  and  rapidly  as  the  latter.  We  may,  therefore, 
find,  upon  section,  diffuse  enlargement  from  connective-tissue  overgrowth, 
but  no  gummatous  deposit  or  accumulation  of  syphilized  cells.  The  change 
'described  may  occur  in  the  connective  tissues  of  the  testis  in  early  syphilis, 
and  produce  permanent  thickening  without  the  slightest  external  evidence 
of  cell-deposit.  In  such  cases  true  gumma  will  quite  likely  develop  in  the 
period  of  sequels  as  a  consequence  of  lymphatic  obstruction  produced  by  the 
lesion  of  the  secondary  or  active  period.  The  diffuse  or  circumscribed  char- 
acter of  the  enlargement  is  all  a  matter  of  accident,  it  being  probable  that  in 
the  circumscribed  form  the  causal  lesion  of  the  secondary  period  was  local- 
ized, consisting  of  a  deposit  analogous  to  the  papular  syphilide;  subsequent 
lymphatic  obstruction  being  also  localized,  the  development  of  a  definite 
node  or  gumma  takes  place.  The  process  may  increase  by  additional  cell- 
deposit  until  the  testis  becomes  quite  large,  often  double  its  natural  size. 
Finally,  if  not  checked,  the  process  results  in  the  formation  of  fibro-con- 
nective  tissue  that  shrinks,  and  thereby  eventually  produces,  on  the  one 
hand,  complete  atrophy  of  the  gland,  and,  on  the  other,  depressions  corre- 


SYPHILOMA    OF    THE    TESTIS. 


971 


sponding  to  the  localized  deposit.  Both  testes  may  be  affected,  but  rarely 
simultaneously,  the  rule  being  that  one  becomes  involved  after  the  other  has 
completely  undergone  characteristic  changes.  Suppuration,  abscess,  and 
fungus  are  not  seen  in  this  form  of  syphilitic  testis. 

Circumscribed  Infiltration. — Localized  gumma  or  syphiloma  may  co- 
exist with  the  preceding  general  changes  or  may  occur  alone.  The  process 
is  merely  an  exaggerated  form  of  the  diffuse  variety  in  which  there  is  a 
superabundance  of  cells  and  distinctly-defined  tumors  of  varying  number 
and  dimensions,  ranging  from  the  size  of  a  millet-seed  to  that  of  a  hen's  egg. 
The  deposit  probably  affects  primarily  the  perivascular  lymph-spaces  or  the 
walls  of  the  spermatic  tubules.    On  section  the  nodules  are  found  to  be  com- 


Fig.  220. — Gumma  of  testis  surrounded  by  sclerosis.      (After  Reclus.) 


posed  of  large,  round,  multinucleated  granular  cells,  with  some  fatty  and 
granular  debris,  bound  together  by  connective  tissue.  The  mass  is  of  a 
pinkish-gray  or  dark-yellow  color,  and  constitutes  the  syphiloma  of  Wagner. 

Results. — The  possible  results  of  these  neoplasms  are:  1.  Resolution 
with  restoration  of  integrity  of  tissue.  2.  Resolution  succeeded  by  partial 
or  complete  atrophy.  3.  Ulceration  or  suppuration.  4.  Ulceration  and 
fungus  testis.  5.  Suppuration  followed  by  sinuses.  6.  Cretaceous  meta- 
morphosis. 

Of  these  various  changes  the  fungus  testis  is  the  most  important  on  ac- 
count of  its  resemblance  to  cancer.  The  gummy  material  infiltrates  the 
envelope  of  the  testis  and  finally  the  skin  covering  it;  ulceration  then  occurs 
and  allows  the  yellowish,  dirty-looking,  exuberant  gummy  material  to  ex- 


973  .  NEOPLASMS    OF    THE    TESTIS. 

trude  itself.  ''Proliferation  still  goes  on  and  the  tubnli  seminiferi  protrude 
with  the  mass,  the  whole  becoming  covered  with  luxuriant  granulations 
bathed  in  pus  and  dried  blood  from  occasional  hemorrhages  that  are  readily 
produced  from  the  fragile  granulations.  In  some  instances  the  entire 
tubular  structure"  of  the  testis  becomes  extruded  in  the  fungus. 

Teeatmext. — Proper  treatment  of  S3rphilitic  testis  generally  promises 
a  successful  result.  It  consists  of  the  administration  of  small  doses  of  mer- 
cury in  combination  with  tonics  and  the  iodid  of  potassium  in  increasing 
doses.  The  local  treatment  should  be  simple  antisepsis  with,  in  cases 
of  fungus,  strapping  and  the  application  of  the  nitrate  of  silver.  The 
fungous  mass  should  not  be  cut  away  or  otherwise  destroyed,  lest  healthy 
tubuli  be  sacrificed.  If  the  tunica  vaginalis  be  filled  with  fluid — secondary 
hydrocele — which  does  not  speedily  absorb,  careful,  systematic  strapping 
should  be  resorted  to.  The  essential  element  of  treatment  is  the  speedy 
production  of  the  physiologic  effects  of  mercury  and  iodin.  The  methods 
of  administration  of  these  drugs  have  been  presented  in  connection  with  the 
treatment  of  syphilis. 

SIMPLE  CHEOXIC  IXDUEATIOX  OF  THE  EPIDIDYMIS. 

Desormeaux,  Fournier,  and  others  have  described  what  thej^  believe  to 
be  a  peculiar  pathologic  entity  affecting  the  testis,  termed  by  them  pseudo- 
tuhercular  epididymitis.  This  condition  is  nothing  more  nor  less  than  sim- 
ple chronic  inflammation  of  the  epididymis,  and  should  be  so  designated. 
The  nomenclature  alluded  to  is  not  only  extremely  unscientific,  but  de- 
cidedly confusing.  The  affection  consists  of  slow  chronic  induration  with, 
perhaps,  suppuration  of  the  epididymis,  occurring  in  a  certain  proportion 
of  cases  after  preceding  acute  or  subacute  inflammation.  The  subjects  of 
this  form  of  disease  are  usually  strumous  or  cachectic,  or  suffering  from 
constitutional  syphilis,  and  the  affection  may  terminate  in  true  tubercular 
testis,  or  the  form  of  cheesy  and  purulent  degeneration  that  is  so  often  suc- 
ceeded by  general  tuberculosis.  In  some  cases  the  pseudotubercular  testis 
may  be  said  to  be  the  preti\bercular  stage  of  the  tubercular  form.  In 
others,  perhaps,  the  condition  is  really  tubercular  from  the  beginning,  but 
does  not  progress  further  than  a  greater  or  less  degree  of  thickening  and  in- 
duration, either  in  the  form  of  circumscribed  nodules  or  uniform  enlarge- 
ment of  the  epididymis.  It  may  be  impossible  to  differentiate  simple  chronic 
inflammation  from  the  milder  types  of  tubercular  infection,  where  no  in- 
disputable primary  focus  of  tuberculosis  is  discoverable.  The  most  impor- 
tant point  for  consideration  is  the  liability  to  secondary  pus  or  tubercular 
infection  in  cases  of  primarily  simple  inflammation.  The  possibilit}^  of  diag- 
nostic confusion  is  obvious. 

Chronic  epididymitis,  in  general,  has  been  sufficiently  expatiated  upon 
in  the  consideration  of  inflammatory  affections  of  the  testis;  hence  does  not 
require  further  elaboration.     Chronic  inflammation  usually  attacks  the  epi- 


TrBEECULOSIS    OF    THE    TESTIS.  973 

didymis  primarily.  It  may,  however,  finally  involve  the  seminal  vesicles, 
vas  deferens,  and  even  the  body  of  the  testis.  The  question  of  suppuration 
depends  upon  the  presence  or  absence  of  mixed  infection  or  tubercle  bacilli. 

TUBEECULOSIS   OF  THE   TESTIS. 

Our  knowledge  of  tubercular  infection  of  the  testis  has  been  very  in- 
complete until  a  comparatively  recent  date.  From  a  pathologic  stand-point, 
the  subject  has  become  fairly  clear,  but  the  clinical  study  of  the  disease  is 
so  tinctured  by  fallacious  nomenclature  and  diagnostic  error  that  the  prac- 
tical application  of  the  results  of  pathologic  study  is  still  of  a  "hit  or  miss" 
character.  Much  of  the  confusion  is,  it  is  true,  assignable  to  certain  sources 
of  error  inseparable  from  the  clinical  manifestations  of  the  disease,  but  there 
is,  nevertheless,  an  urgent  demand  for  conservatism  in  diagnosis,  and  the 
surgeon  shordd  be  chary  of  dogmatic  opinions  where  agnosticism  is  the  only 
conscientious  and  logical  attitude  to  assume. 

Tuberculosis  of  the  testis  is,  as  a  rule,  apparently  a  continuation  of 
chronic  suppurative  or  simple  inflammation;  it  may,  however,  occur  spon- 
taneously, without  any  pre-existing  causal  condition,  or  present  itself  as  a 
deposit  secondary  to  tubercle  elsewhere.  .  The  tubercular  process  in  the  first 
instance  has  its  point  of  departure  in  caseation  of  inflammatory  deposit  in 
tissues  the  vitality  of  which  is  depraved  by  systemic  derangement  or  heredi- 
tary predisposition,  the  deposit  occurring  inside  of,  as  well  as  external  to, 
the  seminal  tubules.  When  tubercular  infection  occurs  secondarily,  it  begins 
by  the  accumulation  of  tubercular  cell-deposit  entirely  outside  the  tubuli. 
Most  modern  pathologists  will,  of  course,  demand  a  demonstration  of  bacilli 
in  every  case  before  accepting  the  diagnosis  of  tubercle.  This  condition  can- 
not, of  necessity,  always  be  fulfilled  clinically.  Buhl's  by  no  means  recent 
theory  of  endothelial  and  blood-infection  still  seems  to  be  the  most  rational 
explanation  of  the  manner  in  which  the  bacilli  produce  the  general  tuber- 
culosis that  in  many  cases  follows  tubercular  testis  sooner  or  later.  It  is 
to  be  remembered  in  this  connection  that  general  tuberculosis  often  follows 
caseous  processes  in  which  bacilli 'either  cannot  be  demonstrated  at  all  or 
only  in  small  number.  This  is  especially  likely  to  be  the  case  in  the  so-called 
pseudotubercular  testis.  Here  the  bacilli  are  the  result  of  secondary  in- 
fection, and  may  have  very  little  affinity  for  the  local  process,  while  never- 
theless producing  general  infection,  the  lungs  being  especially  liable  to  in- 
volvement. 

From  a  clinical  stand-point  there  is  a  broad  line  of  demarkation  be- 
tween the  various  phases  of  testicular  tuberculosis.  The  disease  confronts 
us  in  several  forms  that,  for  practical  purposes,  are  susceptible  of  distinct 
classification.  Thus  we  meet  with:  1.  Cases  secondary  to  tuberculosis  in 
situations  remote  from  the  testis.  2.  Cases  secondary  to  tuberculosis  of  con- 
tiguous parts.    3.  Cases  secondary  to  tuberculosis  of  correlated  tissues  and 


974  NEOPLASMS    OF    THE    TESTIS. 

organs:  i.e.,  tuberculosis  of  the  genito-iirinary  tract.  4.  Cases  secondary 
to  known  traumatic  inflammation.  5.  Cases  secondary  to  simple  or  gonor- 
rheal infection  of  the  testis.  6.  Cases  in  which  the  tuberculosis  follows  pus- 
infection  and  suppuration,  which  is  itself  secondary  to  inflammation,  trauma, 
or  specific  infection.  7.  Cases  in  which,  with  respect  to  the  tubercular  in- 
fection per  se,  the  testicular  disease  is  the  primary  condition  and  produces, 
secondarily,  disease  of  other  structures,  the  genito-urinary  tract  and  lungs 
being  especially  likely  to  become  involved. 

The  etiologic  relation  of  traumatism  to  tuberculosis  of  the  testis  is  of 
great  importance.  Traumatisms  so  slight  as  to  hardly  attract  attention  may, 
especially  if  an  inherent  predisposition  exists,  be  followed  at  a  period  more 
or  less  remote  by  tubercular  infection.     Experimental  research  bears  out 


Fig.  221. — Disseminated  tuberculosis  of  the  body  of  tbe  testis. 
(After  Osborne.) 

what  has  been  said  regarding  traumatism  of  the  testis  in  its  relations  to 
tubercular  infection  of  the  organ.  Bacilli-laden  sputum  has  been  injected 
into  the  circulation  of  animals  without  result,  so  far  as  the  testis  was  con- 
cerned, until  the  testicle  was  contused,  when  tubercular  infection  of  the 
organ  followed  quite  uniformly.  The  bacillus  tuberculosis  has  been  found 
in  apparently  healthy  testes.  Under  such  circumstances  tuberculosis  of  the 
testis  might  naturally  be  expected  to  follow  inflammation,  however  produced. 
MoEBiD  Anatomy. — -It  is  unnecessary  to  expatiate  exhaustively  upon 
the  pathologic  anatomy  of  tubercular  testis,  inasmuch  as  it  is  that  of  tuber- 
cular disease  in  general.  The  most  important  point  is  that  the  epididymis 
is  generally  the  primary  focus  of  infection.  Broadly  speaking,  the  disease 
is  found  post-mortem  to  be  divisible  into  the  following  types:     1.  Tuber- 


TUBERCULOSIS    OF    THE    TESTIS. 


975 


cular  testis  with  associated  general  tuberculosis,  the  general  disease  being, 
with  respect  to  the  testicular  disease :   (a)  primary, . (b)  secondary. 

2.  Tubercular  testis  with  associated  tubercular  disease  of  the  genito- 
urinary organs,  the  associated  infection  being  (a)  primary,  (b)  secondary,  to 
the  testiciilar  disease.  The  prostate  and  seminal  vesicles  are  especially  liable 
to  be  affected. 

3.  Tubercular  testis  limited  to  the  epididymis:  (a)  circumscribed;  (&) 
diffuse.    This  is  often  very  benign. 

4.  Tuberculosis  of  the  epididymis,  with  involvement  of  the  body  of  the 
testis. 

5.  Tubercular  testis  proper,  without  epididymal  disease:  (a)  circum- 
scribed;  (&)  diffuse. 

6.  Tubercular  disease  of  the  testis — epididymis  or  body — with  (a)  pri- 


Fig.  222. — Tuberculosis  of  the  epididymis.     (After  Monod  and  Terrillon.) 


mary  caseation;  (h)  secondary  caseation;  (c)  primary  suppuration;  (d)  sec- 
ondary suppuration. 

The  anatomic  characters  vary  according  to  the  nature  of  the  infection; 
thus,  the  infection  radiates  from  a  primary  focus — usually  epididymal — in 
the  majority  of  cases,  the  process  showing  a  gradual  infiltration  from  the 
point  of  primary  departure,  while  in  other  instances  disseminated  miliary 
tuberculosis  exists  from  the  beginning.  The  latter  is  the  class  of  cases  most 
often  associated  with  primary  general  infection.  It  may,  however,  be  the 
result  of  a  secondary  general  infection  to  which  the  original  focus  of  tes- 
ticular tuberculosis  bears  a  primary  relation. 

Symptoms. — The  first  thing  noticeable  is  usually  an  irregular,  nodular 
enlargement,  most  frequently  limited,  primarily,  to  the  epididymis.  This 
is  succeeded  later  on  by  thickening  and  induration  of  the  vas  deferens,  and 
sometimes  the  body  of  the  organ.     The  seminal  vesicles  often  become  in- 


976  NEOPLASMS    OF    THE    TESTIS. 

volved,  more  rarely  the  prostate,  bladder,  and  kidneys,  in  the  order  named. 
There  is  little  or  no  joain  and  very  slight  tenderness  on  pressure.  The  gen- 
eral condition  of  the  jDatient  varies  with  the  character  and  duration  of  the 
infection,  depending -largely  on  whether  the  infection  of  the  testis  is  pri- 
mary or  secondary,  and  what,  if  any,  organs  are  involved  beside  the  testis. 
In  the  slighter  cases  the  process  may  limit  itself  to  the  primary  nodule  and* 
finally  become  quiescent,  at  no  time  producing  any  observable  general  dis- 
turbance, the  patient  remaining  apparently  healthy  aside  from  the  local 
tubercular  process.  It  is,  of  course,  difficult  to  differentiate  these  cases  from 
simple  chronic  inflammation,  but  the  author  inclines  to  the  belief  that  they 
are  more  often  seen  than  usually  supposed.  The  excellent  general  condi- 
tion Avith,  incidentally,  a  high  degree  of  local  resistance,  is  a  sufficient  ex- 
planation for  the  mildness  and  circumscribed  limitation  of  the  disease. 
There  is  no  way  of  establishing  a  positive  diagnosis  in  many  instances,  but 
it  is  well  to  regard  nodular  thickenings  of  the  epididymis — especially  if  non- 
venereal  in  origin — as  open  to  suspicion.  Possible  sources  of  simple  or  gon- 
orrheal infection  must,  of  course,  be  carefully  sought  for.  Even  though  the 
testicular  disease  be  traced  to  a  probable  source  of  infection  other  than  tuber- 
culosis, it  is  to  be  remembered  that  inflammatory  j)rocesses  in  the  testis, 
"whatever  their  origin,  are  a  standing  invitation  to  tubercular  infection.  A 
conservative  and  cautious  opinion  is,  therefore,  alwaj^s  wise.  When  the  local 
process  becomes  serious,  and  when  the  testicular  tuberculosis  is  part  of  a 
general  infection,  primary  or  secondary,  the  appearance  of  the  patient  is 
the  same  as  in  all  tubercular  and  chronic  suppura,tive  processes.  In  pro- 
gressive cases,  emaciation,  night-sweats,  and,  finally,  general  or  pulmonary 
tuberculosis  supervene  after  a  variable  time,  the  course  of  the  disease  being 
usually  quite  slow.  Abscesses  and  fistulas  eventually  form  in  the  testicle 
and  burrow  in  various  directions.  In  rare  cases  the  patient  may  possess  a 
fistulous,  nodular  testicle  for  some  years  without  evident  impairment  of 
health.  This  is  rare,  however,  for  the  patient  is  usually  cachectic  and  greatly 
debilitated. 

The  symptomatology  and  course  of  tubercular  testis  are  obviously  modi- 
fied by  the  degree  and  character  of  associated  infection.  Such  symptomatic 
modifications,  however,  are  incidental,  and  their  detailed  description  is  of 
no  importance  in  discussing  the  characteristics  of  testicular  tuberculosis 
per  se. 

Treatment. — In  the  incipiency  of  tubercular  testis  the  diagnosis  is 
often  so  obscure  that  treatment  must  necessarily  be  quite  conservative.  In 
cases  where  the  diagnosis  is  doubtful  syphilis  is  the  most  important  source 
of  fallacy.  It  may  be  excluded  by  a  few  Aveeks'  thorough  antisyphilitic 
treatment,  in  which  the  iodids  should  preponderate,  the  lesio.n  being 
generally  gummatous,  if  syphilitic.  If,  however,  a  probable  diagnosis  of 
tubercular  testis  seems  Jiistifiable,  vigorous  treatment  must  at  once  be  in- 
stituted.    The  necessity  for  this  is  beyond  cavil,  where  a  positive  diagnosis 


TUBEECULOSIS    OF    THE    TESTIS.  977 

can  be  made.  In  cases  secondary  to  general  tuberculosis,  or  resulting  from 
infection  extending  from  tuberculosis  of  associated  parts,  notably  the  genito- 
urinary tract,  the  testicular  disease  may  play  but  a  minor  role  in  the  path- 
ologic enseinble  and  may  therefore  require  little  or  no  treatment  aside  from 
that  directed  to  the  cure  of  the  primary  condition. 

Constitutional  Measures. — The  usual  antitubercular  routine  of  change 
of  climate,  life  in  the  ojDcn  air,  and  such  remedies  as  guaiacol,  iodin,  cod- 
liver-oil,  iron,  and  hypophosphites  are  indicated.  Hypodermic  medication 
comes  into  play,  Just  as  in  other  forms  of  tuberculosis.  The  hypodermic  use 
of  nucleins,  as  prepared  by  Vaughn,  is  sometimes  effective.  This  method 
may  demand  many  months  of  careful  application  to  decide  its  merits.  Iodo- 
form emulsion  may  be  used  in  a  similar  manner  and  is  often  of  service  when 
conjoined  with  suitable  local  measures.  Gold  is  oftentimes  valuable  in  con- 
junction with  iodin,  hypodermically,  in  the  preparations  known  as  Clark's 
solutions  of  gold  and  iodin.  The  best  preparation  for  internal  administra- 
tion is  Barclay's  solution  of  the  bromids  of  gold  and  arsenic. 

Local  Measures.- — Injections  of  iodoform  emulsion  into  the  affected  area 
are  often  serviceable.  The  iodoform  does  double  duty,  as  it  enters  the  cir- 
culation and  attacks  the  tubercular  infection  via  the  blood.  Zinc  chlorid 
has  been  used  in  a  similar  manner.  Fifteen  to  20  drops  of  20-per-cent. 
emulsion  of  iodoform,  or  5  to  10  drops  of  a  5-per-cent.-zinc-chlorid  solution 
may  be  injected  into  the  tubercular  mass  every  three  or  four  days.  In  some 
cases  reaction  is  slight  and  iodoform  may  be  injected  daily.  Operative  meas- 
ures are  to  be  adopted  very  cautiously.  Excision  of  the  tubercular  foci  in 
such  a  manner  as  to  preserve  the  testis  may  be  practiced  in  selected  cases 
after  other  measures  have  proved  ineffectual.  Extirpation  of  infected  glands 
in  the  groin  may  be  simultaneously  required.  The  frequency  with  which 
tubercular  testis  is  associated  with  tuberculosis  of  other  organs  necessarily 
limits  the  applicability  of  operative  treatment.  The  author  believes,  how- 
ever, that  in  certain  cases  too  much  conservatism  is  exhibited  in  this  respect. 
Genera]  improvement,  even  an  apparent  restoration  of  health,  is  not  impos- 
sible after  complete  extirpation  of  a  disorganized  tubercular  testis,  although 
the  lungs,  the  opposite  testis,  or  even  the  urinary  tract  may  appear  to  be 
already  involved.  Especially  is  this  true  of  cases  in  which  the  testis  is  the 
primary  focus  of  infection. 

The  following  cases  illustrate  this  point: — 

Case  1. — A  man,  40  years  of  age,  had  suflfered  an  attack  of  epididymitis  some 
months  before,  followed  by  chronic  induration,  abscesses,  and  sinuses.  Numerous 
attempts  had  been  made  to  cure  the  disease  by  cauterization  and  free  incisions. 
Meanwhile  great  debility  and  emaciation  with  persistent  cough  and  hectic  symptoms 
supervened,  and  it  became  evident  that  pulmonary  infection  had  begun  and  that 
further  conservatism  would  deprive  the  patient  of  all  chance  of  recovery.  The  testis 
and  several  infected  inguinal  glands  were  therefore  removed.  The  affected  organ  was 
found  to  be  riddled  with  indurated  sinuses,  and  contained  several  cheesy  foci;  the 
vas  deferens  was   infiltrated  for  about  two   inches;     the   epididymis   was   hard   and 


978  NEOPLASMS    OF    THE    TESTIS. 

nodular,  with  several  spots  of  softening.  The  microscope  verified  the  diagnosis.  The 
improvement  following  operation  was  remarkable,  the  patient  gaining  some  fifteen 
pounds  weight  in  about  six  weeks  and  the  cough  entirely  disappearing.  The  sub- 
sequent history  of  this  case  is  unsatisfactory,  because  of  the  patient's  death  some 
months  later  of  combined  acute  pneumonia  and  alcoholism. 

Case  1. — Another  interesting  and  instructive  case  Avas  that  of  a  man,  35  years 
of  age,  who  had  had  suppuration  and  sinuses  of  the  testis  for  more  than  a  year.  His 
general  health  had  deteriorated  greatly;  he  was  greatly  emaciated  and  had  an  irri- 
tating, extremely  annoying  cough.  Treatment  of  all  kinds  had  been  faithfully  tried 
without  avail.  Examination  of  the  lungs  showed  feeble  respiration  and  slight  apical 
dullness.  Kight-sweats  had  been  troublesome  for  several  weeks.  There  was  no  in- 
volvement of  the  lymphatic  glands.  After  a  month's  ineffectual  antisyphilitic  treat- 
ment the  testis  was  removed.  It  was  found  to  be  greatly  enlarged,  nodular,  and 
riddled  with  sinuses,  the  changes  in  the  epididymis  being  especially  marked.  In  the 
center  of  the  enlarged  body  of  the  testis  was  a  cavity  the  size  of  a  walnut,  containing 


Fig.  223. — Cancer  of  right  testis.     (]Monod  and  Terrillon.) 

cheesy  detritus  and  pus,  and  strongly  resembling  the  cavities  of  a  caseating  pneu- 
monic lung.  The  microscope  showed  the  ordinary  characteristics  of  tuberculosis. 
Improvement  was  even  more  remarkable  than  in  the  preceding  case,  the  patient 
getting  around  in  ten  days  and  gaining  some  sixteen  pounds  in  weight  Avithin  a 
month.  The  cough  ceased,  and  the  general  strength  returned,  being  apparently  better 
than  before  the  testicular  disease  developed.  One  year  after  operation  the  patient 
presented  himself  with  a  nodular  induration  of  the  remaining  epididymis.  A  change 
of  climate  was  advised,  and  he  went  to  Southern  Calif oniia,  where  he  sojourned  for 
about  a  year,  at  the  end  of  Avhich  time  he  returned  and  was  again  examined.  The 
epididymis  was  still  indurated,  but  no  longer  nodular,  and  perceptibly  smaller;  the 
general  health  was  excellent,  and  there  Avas  no  cough.  When  the  ease  Avas  last 
heard  from,  three  years  after  operation,  there  had  been  no  further  trouble,  and  the 
patient  had  become  quite  stout. 

In  operating  for  tiibercnlar  testis  there  should  be  no  half-way  measures. 
Free  excision  of  nodules,  or  curettement  of  cavities  in  the  event  of  operations 


MALIGXAXT    TUMORS    OF    THE    TESTIS. 


979 


designed  to  save  the  testis  proper,  and  high  section  of  the  cord  in  cases  of 
complete  castration  are  essential.  Especial  care  should  be  taken  to  trace 
out  the  yas  deferens,  as  it  will  often  be  found  to  be  infiltrated  for  some  dis- 
tance above  the  testis.  It  may  be  necessary  to  follow  it  up  within  the  in- 
guinal canal. 

With  reference  to  castration  in  cases  in  which  the  tubercular  process  in- 
volves other  parts — either  primarily  or  secondarily — the  author  believes 
that  nothing  is  lost,  and  much  can  be  gained,  by  removing  a  caseating  or 
suppurating  testis,  which,  to  say  the  least,  is  a  constant  drain  upon  the 
patient's  vitality  and,  in  addition,  a  source  of  toxemia  and  mixed  infection. 
Cases  also  arise  in  which  castration  may  retard  or  even  check  secondary  in- 
fection of  the  lungs.  Improvement  in  the  general  health  at  least  is  quite 
likely  to  result  from  the  operation  in  many  cases. 


Fig.  224. — Encephaloid  of  testis.     (After  Monod  and  Terrillon.) 


MALIGNANT  TUMOES  OF  THE  TESTIS. 

Malignant  disease  of  the  testis  is  not  frequent,  yet,  as  compared  with 
the  other  forms  of  tumor  that  will  shortly  be  described,  it  is  by  no  means 
rare.  It  may  occur  in  several  forms,  the  most  frequent  of  which  is  the  soft, 
brain-like  variety,  formerly  known  as  encephaloid,  more  recently  and  ob- 
scurely classified  as  "medullary  sarcoma." 

Encephaloid. — This  may  either  be  primary  or  due  to  secondary  trans- 
formation of  the  soft  or  other  variety  of  true  sarcoma.  Scirrhus  is  cer- 
tainly rare,  unless  as  a  deposit  secondary  to  cancer  in  other  situations, 
and  the  same  may  be  said  of  colloid  and  melanotic  cancer.  Epithelioma 
may  occur,  being  secondary  to  epithelial  cancer  of  the  penis  and  scrotum. 
Soft  cancer  of  the  testis,  like  that  of  other  organs,  is  a  disease  of  youth 


980 


NEOPLASMS    OF    THE    TESTIS. 


and  childhood,  occurring  even  in  young  infants;  it  is  very  rare  after  middle 
age,  and  is  most  common  from  pirherty  to  the  age  of  thirty.  Its  causes  are 
unknown,  hut  in  some  cases  it  is  attributable  to  heredity  and  injury  com- 
bined, the  latter  cause  being,  perhaps,  a  forgotten  element  in  the  history  of 
the  case. 

Symptoms  and  Course. — The  clinical  history  of  encephaloid  of  the 
testis  is  that  of  rapid  enlargement  of  the  testis  with  more  or  less  serous 
effusion  into  the  tunica  vaginalis — secondary  hydrocele — and  later  on  en- 
largement of  contiguous  hanphatic  glands  with  severe  and  sometimes  ago- 
nizing pains  of  a  cutting  or  lancinating  character.  The  tumor  is  ovoid,  elas- 
tic, or  semifluctuating,  the  latter  feature  being  easily  mistaken  at  some 
points  for  true  fluctuation.  Yaricocity  of  the  veins  of  the  scrotum  and  lower 
extremity  on  the  affected  side,  with  more  or  less  edema  of  the  foot  and  leg. 


Fig.  225. — Section  of  cancer  of  testis,  showing  fibrous  stroma  and  alveoli  filled 
with  epithelial  cells.     (After  Kocher.) 


are  likely  to  result  from  pressure,  secondary  enlargement  of  the  pelvic  glands 
having  much  to  do  with  this.  The  pain  is  most  severe  where  secondary 
glandular  infection  is  pronounced,  with  resultant  pressure  upon  important 
nerves.  In  some  cases  the  tumor  does  not  develop  rapidly  and  steadil}^,  but 
has  intermittent  accessions  of  growth. 

The  tumor  may  attain  a  very  large  size,  a  weight  of  nine  pounds  having 
been  reported.  It  finally  involves  the  scrotum,  which  becomes  adherent  to 
the  tumor  and  ulcerates.  Under  these  circumstances  a  fungous  mass  of 
granulation  tissue,  seminal  tubules,  and  granular  debris  forms  and  attains 
some  size;  this  is  the  fungus  hematodes — so  termed  from  its  tendency  to 
bleed — constituting  what  was  formerly  called  in  popular  language,  the  "rose 
cancer.^'  With  its  envelopment  of  pus  and  decomposing  blood,  this  forms  a 
very  unsavory-looking  mass.  The  cancerous  cachexia  develops  after  a  time 
and  the  patient  eventually  dies,  worn  out  by  pain,  exhaustion  from  hemor- 


MALIGNANT    TUMOES    OF    THE    TESTIS. 


981 


rliage,  and  secondary  sepsis.  The  bladder,  prostate,  and  kidneys,  more 
rarely  other  and  distant  organs,  may  eventually  become  infected, — not  by 
metastasis,  as  once  believed,  but  by  direct  infection  from  migratory  cancer- 
cells.  The  prognosis  of  cancer  of  the  testicle  is  worse,  if  possible,  than  in 
other  situations.  The  disease  always  returns  after  extirpation,  generally  in 
some  portion  of  the  genito-urinary  tract,  often  in  the  kidney.  It  may  in- 
vade the  remaining  testicle.  Cases  of  alleged  cure  have,  been  reported,  but 
it  is  probable  that  the  operators  would  have  lost  the  glory  of  their  opera- 
tive cure  of  cancer  if  they  had  first  tried  mercury  and  iodin  internally  for  a 
few  weeks.  The  possibility  of  hereditary  syphilis  must  be  duly  considered 
in  children  and  youths. 

Treatment. — The  treatment  consists  in  early  removal,  in  the  hope  of 


Fig.  226. — Monocystic  testis.     (After  Kocher.) 


prolonging  life;  operation  is  rarely  admissible,  however,  if  glandular  infec- 
tion has  occurred. 

In  rapidly-growing  testicular  tumors  in  which  malignancy  is  suspected, 
syphilis  should  be  excluded  by  the  microscope  or  by  careful  and  vigorous 
treatment,  after  which  there  is  no  excuse  for  delay  in  operating.  Once  a 
positive  diagnosis  is  possible,  operation  simply  postpones  the  inevitable. 
In  operating  the  testis  should  be  thoroughly  exposed  by  an  exploratory 
incision  as  a  further  precaution  against  diagnostic  error. 

Saecoma. — Typic  sarcoma  of  the  testis  is  very  rare,  and  blends  so  in- 
timately with  true  cancer  that  it  is  rather  indefinite  as  an  entity,  the 
majority  of  cases  merging  sooner  or  later  into  encephaloid.  The  differ- 
ence between  sarcoma  and  cancer  of  the  testis  is  a  matter  of  microscopic 


983 


NEOPLASMS    OF    THE    TESTIS. 


technicality  ratlier  than  clinical  observation.  The  pure  cases  of  sarcoma  are 
generally  cystic  or  fibrocystic,  and  are  less  likely  to  merge  into  encephaloid 
than  is  soft  sarcoma.  The  disease  occurs  in  comparatively  young  persons, 
rarely  attacking  those  over  thirty  years  of  age.  One  side  is  generally  at- 
tacked, very  rarely  both.  The  tumor  usually  develops  without  apparent 
cause  and  is  of  slow  growth.  It  is  comparatively  painless  until  it  becomes 
so  large  that  it  produces  mechanic  inconvenience  and  painful  dragging  on 
the  spermatic  cord  or  is  bruised  in  the  movements  of  the  body.  The  soft 
sarcoma  may  develop)  very  rapidly,  and  merge  into  encephaloid  so  speedily 
that  the  "precancerous"'  stage  is  with  difficulty  appreciable.  The  growth 
primarily  invades  the  body  of  the  testis,  but  sooner  or  later  attacks  the  epi- 
didj^mis,  and  the  whole  tumor  becomes  a  smooth  homogeneous  mass,  unless 


Fio^.  227. — MulticYstic  deaeneration  of  testis. 


peripheral  cystic  degeneration  is  present,  in  which  case  it  is  more  or  less 
uneven  to  the  feel,  or,  more  rarely,  lobulated.  An  enormous  size  may  be  at- 
tained if  the  disease  does  not  become  malignant  at  a  very  early  stage  of  its 
development;  in  rare  instances  it  may  remain  more  or  less  quiescent  for 
some  5^ears  and  then,  without  apparent  cause,  suddenly  take  on  cancerous 
transformation. 

Treatment. — The  treatment  of  sarcoma  is  purely  surgical  and  consists 
of  early  castration.  Attention  is  again  called  to  the  advisability  of  a  course 
of  antis3'philitic  treatment  for  a  reasonable  time  in  all  tumors  of  the  testicle, 
no  matter  how  plain  the  diagnosis  of  non-syphilitic  growth  may  seem  to  be, 
and — with  due  deference  to  microscopic  expertness — no  matter  what  the 
microscope  may  apparently  demonstrate.  This  is  a  harmless  as  well  as  valu- 
able rule. 


DIAGNOSIS    OF    NEOPLASMS    OF    THE    TESTIS. 


983 


Eaeee  FoEiis  OF  TuMOE  OF  THE  TESTIS. — These  comprise  lipoma,  myx- 
oma, myoma  (myofibroma),  dermoid  cysts,  multiple  cystic  degeneration,  and 
enchondroma.  These  growths  are  the  same  from  a  pathologic  stand-point  as 
similar  types  occurring  in  other  situations,  and  require  no  special  consid- 
eration. Their  treatment  is  either  castration  or  excision  of  the  tumor,  ac- 
cording as  the  growth  involves  the  whole  testis  or  is  merely  a  local  affair 
susceptible  of  removal  without  damage  to  the  normal  tissue.  This  is  an 
important  consideration,  for,  if  only  a  small  portion  of  the  secreting  structure 
is  left,  the  generative  function  of  the  diseased  organ  is  not  destroyed  by 
operation;  always  providing,  however,  that  the  epididymis  be  intact  or  at 
least  pervious.  In  case  both  testes  are  involved,  a  portion  of  one  or  both 
organs  may  be  sufficient  to  preserve  virility,  even  though  the  patient  is  ren- 
dered sterile. 

Keyes  has  formulated  the  following  excellent  diagnostic  table  of  the 
most  important  neoplasms  of  the  testis.  Exception  can  only  be  taken  to  the 
somewhat  arbitrary  differentiation  of  cancer  and  sarcoma. 


Tubercular  Testis. 


1.  Most  common   in  early 
youth  and  manhood. 

2.  No  change  in  scrotal  veins. 


3.  Does  not  grow  to  great  size. 

4.  Holds  second  place  of 
frequency. 

5.  Primarily   affects  epididy- 
mis. 

6.  Form   knotty,  irregular, 
hard,  especially  the  epididymis. 

7.  Development  slow. 

8.  Pain    absent  or    insignifi- 
cant. 


9.  Often   discovered   by  acci- 
dent. 


10.  Usually  no  sensation'  on 
pressure,  neither  pain  nor  the 
normal  sensation. 


11.  Fluid  in  tunica  vaginalis 
sometimes. 


12.  Tendency    to    suppurate, 
discharge,  and  leave  fistula. 


13.  Both  testes  often  consec- 
utively attacked. 

14.  Loss  or  impairment  of 
sexual  desire  and  power  when 
both  glands  are  involved. 


1.5.  Fungus  not  very  common. 
If  found  it  is  pale  and  soft, 
bleeding  rather  easily,  composed 
mainly  of  gi'anulations.  Pus 
thin,  sinuses  leading  into  tes- 
ticle; growth  slow;  usually 
painless. 


Syphilitic  Testis. 


1.  Most  common  in  middle 
or  later  life. 


8.  Comparatively  small. 


4.  Most  common  of  the 
four. 

.5.  Primarily  aff'ects  body 
of  testis. 

6.  May  be  perfectly  smooth 
and  oval  o  r  more  o  r  less 
lumpy. 


8.  Often    absolutely    no 
pain. 


11.  Fluid  in  tunica  vagi- 
nalis nearly  always. 

12.  Tendency  to  atrophy 
without  external  opening ; 
sometimes  there  are  dis- 
charge and  fungus. 

13.  Same. 


14.  Same  and  more 
marked;  sometimes  exists 
when  one  gland  only  is  dis- 
eased. 

15.  Fungus  very  rare.  If 
found,  i  t  i  s  hard,  yellow, 
mainly  composed  of  tubes 
and  yellow  syphilitic  matter ; 
does  not  bleed  very  easily; 
no  sinuses;  growth  slow; 
painless. 


1.  Most  common  in  youth. 


2.  Scrotal  veins  become 
enlarged  and  varicose  from 
pressure  of  cancerous  glands 
above. 

3.  May  reach  an  immense 
size. 

4.  Holds  third  place. 


6.  Uneven;  prominent, 
hard  and  soft  spots ;  indef- 
inite fiuctuation. 

7.  Development  rapid. 


8.  Pain  liable  to  be  severe 
soon  after  commencement, 
sometimes  excruciating. 

9.  Recognized  by  pains 
from  the  start. 


10.  Darting,  sharp  burn- 
ing paroxysms  and  constant 
pains,  aggravated  by  hand- 
ling. 

11.  Fluid  in  tunica  vagi- 
nalis, usually  slight. 

12.  Tendency  to  open  and 
form  fungus  hematodes. 


13.  Usually  only  one  tes- 
ticle suffers. 

14.  Both  glands  not  in- 
vol  ved  s  i  m  u  1 1  a  n  e  0  u  s  1  v; 
hence  not  at  first  necessarily 
impaired. 

15.  Fungus  constant  if 
testis  remains  long  enough  ; 
grows  rapidl}';  bleeds  pro- 
fusely; sloughs  readily;  is 
covered  with  sanious.  badly- 
smelling  ichor:  is  formed 
mainly  of  cancer-tissue;  is 
very  painful. 


1.  Most   common  in  early 
manhood. 

2.  No  change. 


3.  May  become  very  large. 

4.  Least  common. 

5.  Same. 


6.  Slightly  uneven,  oval, 
perhaps  with  points  of  fluctu- 
ation. 

7.  Very  slow,  often  sud- 
denly becoming  rapid. 

8.  No  pain. 


9.  Tumor  grows  rapidly 
and  is  usually  discovered 
when  small. 

10.  No  pain:  squeezing 
testicle  often  produces  feeling 
of  faintness. 


tunica  vagi- 


11.  Fluid 
nalis  rarely. 


12.  No  tendency  to  open  or 
to  form  fungus. 


13.  Same. 

14.  Same. 


1.5.  No  fungus. 


984 


CASTEATIOX. 


Tubercular  Testis. 


Syphilitic  Testis. 


16.  No  glandular  enlarge- 
ment. 


17.  Verj  rebellious  to  medical 
treatment. 


18.  Cord    always    affected 
eventually. 


19.  Vesieulse  seminales  liable 
to  be  involved. 


20.  Lumpy  to  the  feel. 

21.  Duration  several  years. 


22.  Prognosis  not  favorable. 
Progress  always  indolent,  entire 
cure  rare. 


17.  If  taken  early,  quickly 
amenable  to  treatinent.  lii 
any  case  always  reducible  in 
size  by  intelligent  treatment, 
to  which  all  doubtful  cases 
should  be  subjected. 

18.  Cord  never  involved  in 
a  pure  case  (?). 

19.  Nothing  of  the  sort. 


20.  Excessively  hard. 


21.  Duration  several 
years,  usually  less  than 
tubercle. 

22.  Prognosis  good,  with 
functions  restored  if  treated  ; 
atrophies  if  not  treated. 


16.  Inguinal  and  pelvic 
glands  involved. 


17.  Treatment  ineffectnal. 
If  cut  out,  returns  elsewhere. 


18.  Cord   affected   in  ad- 
vanced disease. 


19.  Nothing. 


20.  Hard  and  soft  in  alter- 
nate spots. 


21.  Duration,  average  two 
years. 


22.  Prognosis  bad.  Kills 
by  cachexia  or  hemorrhage  if 
not  removed,  by  return  else- 
where if  extirpated. 


16.  Glands  sometimes  in- 
volved. 

17.  Medical  treatment  inef- 
fective. If  cut  out,  does  not 
necessarily  reappear ;  if  left, 
cancerous  degeneration  may 
occur. 


18.  Cord  never  affected. 

19.  Nothing. 

20.  Elastic. 


21.  Duration   many  years 
(?)• 


22.  Prognosis  good  :  does 
not  return  if  removed  (?).  If 
left,  liable  to  become  cancer- 
ous. 


It  must  be  remembered  that  the  diagnostic  features  outlined  in  the 
above  table  are  modified  by  the  tyj^ic  or  atypic  character  and  stage  of  each 
disease.  If  Keyes  intends  the  table  to  be  so  arbitrary  as  it  appears, — as  he 
probably  does  not, — it  is  certainly  open  to  criticism  and  may  mislead  the 
practitioner.  The  author  has  interpolated  interrogation  points  to  indicate 
the  portions  of  the  diagnostic  table  that  seem  to  him  to  be  unsupported 
clinically. 

CASTEATIOX. 

The  operation  of  castration  for  incurable  disease  of  the  testis  or  for  en- 
larged prostate  is  exceedingly  simple.  The  scrotum  having  been  shaved, 
scrubbed,  and  aseptized,  a  general  anesthetic  is  usually  given.  The  author 
has  performed  the  operation  under  cocain.  The  testis  is  grasped  in  the  left 
hand  and  the  scrotum  made  tense  over  it.  A  longitudinal  incision  is  made 
and  the  organ  rapidly  exposed  and  freed  from  the  scrotum,  from  which  it 
readily  separates  unless  the  latter  is  infiltrated  by  neoplasm.  The  membrane 
connecting  the  testis  and  scrotum  posteriorly  is  divided  anct  the  cord  pulled 
down  and  freed  as  high  up  as  possible.  The  cord  should  now  be  transfixed 
with  a  stout  catgut  ligature  above  the  proposed  line  of  section,  so  that  it 
may  not  retract  within  the  canal  beyond  control  after  division.  The  cord  is 
divided,  the  testis  removed,  and  the  spermatic  arteries  tied  with  catgut.  It 
is  wise  to  suture  the  stump  of  the  cord  into  the  inguinal  ring,  lest  hemor- 
rhage subsequently  occur  and  give  serious  trouble  in  finding  and  tying  the 
bleeding  vessels.  In  some  cases  it  is  necessary  to  remove  a  greater  or  less 
amount  of  scrotum  in  castrating  for  neoplasm.  The  surgeon  need  have  no 
hesitancy  in  removing  as  much  as  is  required  for  complete  removal  of  the 
disease;  repair  is  rapid  in  this  region,  and  an  entire  new  scrotum  is  readily 
formed  by  grafting,  or  sliding  skin-flaps  if  necessary. 


CHAPTEE  XLIII. 

Varicocele. 

Varicocele  of  greater  or  less  degree  of  severity  is  a  very  frequent 
affection  of  the  male  genito-urinary  apparatus.  Fortunately,  however,  it 
is  not  intrinsically  a  serious  disease,  and  in  the  majority  of  cases  is  tolerated 
indefinitely,  producing,  as  a  rule,  comparatively  little  discomfort.  In  a  cer- 
tain proportion  of  cases,  however,  the  disease  becomes  sufficiently  pro- 
nounced to  induce  the  patient  to  consult  the  surgeon,  and  to  justify  the  use 
of  mechanic  support  or  even  operative  surgical  procedures  for  its  relief. 

The  disease  consists  of  dilation  of  and  associated  degenerative  changes 
in  the  plexus  of  veins  surrounding  the  spermatic  cord — the  spermatic  or 
pampiniform  plexus.  In  a  general  way,  these  changes  resemble  those  oc- 
curring in  varix  in  other  situations,  the  causes  being  also  essentially  the 
same  if  we  exclude  the  iniiuence  of  masturbation  and  sexual  excess. 

Frequency. — Varicocele  occurs  in  quite  a  large  number  of  subjects,  the 
proportion,  according  to  some  authorities,  being  as  high  as  1  in  10.  Lan- 
douzy,  an  early  French  writer,  stated  that  it  occurred  in  60  per  cent,  of 
adult  males.  This  is  undoubtedly  an  exaggeration,  unless  we  accept  as  vari- 
cocele the  slighter  forms  of  dilation  of  the  spermatic  veins. 

Henr}^,  of  New  York,  found  but  41  varicoceles  in  nearly  2000  exami- 
nations as  police-surgeon,  but  this  observation  is  not  an  accurate  criterion 
of  the  frequency  of  the  disease;  the  applicants  for  positions  upon  the 
Xew  York  police-force  are  certainly  excejDtional  from  a  physical  stand- 
point, and,  on  the  average,  less  liable  to  develop  varicocele  than  almost  any 
class  of  men  that  could  be  mentioned.  In  examining  men  for  military 
service  the  author  has  found  distinct  varicocele  in  about  5  per  cent,  of ' 
applicants. 

The  frequency  of  varicocele  diminishes  rapidly  with  increasing  age. 
J\I.  Horteloup,  surgeon  to  the  Bicetre,  found  42  subjects  with  varicocele 
among  1600  individuals,  and  of  these  but  16  were  above  twenty-five  years 
of  age;  of  the  total  number  of  cases  observed,  14  increased  as  the  patients 
grew  older,  19  remained  stationary,  8  diminished,  and  1  entirely  disappeared. 

Varicocele  is  much  more  frequent  than  varices  in  other  situations,  this 
being  dne  to  the  fact  that  there  exists,  in  addition  to  the  general  causes  of 
venous  dilation,  certain  special  causes  due  to  anatomic  peculiarities  of  the 
affected  part.  The  veins  that  return  the  blood  from  the  testis  are  of  con- 
siderable size,  and  follow  a  winding  course  as  they  leave  the  organ  and 
ascend  upon  the  spermatic  cord.  They  are  peculiarly  arranged,  constituting 
a  rich  plexus  of  vessels  surrounding  the  cord  and  anastomosing  at  frequent 
intervals.  The  valves  of  the  veins  composing  this  plexus  are  very  defective, 
and  with  slight  pressure  it  is  possible  to  inject  fluid  from  above  downward 

(985) 


986  VAEICOCELE. 

past  the  valves.  As  compared  with  the  veins  in  other  portions  of  the  body, 
those  of  the  pampiniform,  or  spermatic,  plexus  are  poorly  supported  by  con- 
nective tissue,  which  is  loose,  sparse,  and  inelastic  in  this  situation.  The 
spermatic  veins  are  very  long,  and  even  if  their  valves  were  not  defective 
would  tend  to  dilation  because  of  the  insufficient  support  to  their  walls 
afforded  by  the  cellular  tissue,  and  the  great  weight  of  the  long  column  of 
blood  that  must  necessarily  rise  perpendicularly  in  order  to  empty  itself 
into  the  large  venous  channels  of  the  abdomen.  Pressure  upon  the  veins 
as  they  traverse  the  inguinal  canal  is  an  important  factor  in  the  etiology  of 
varicocele,  and  is  due  to  straining  efforts  of  various  kinds,  particularly  those 
involved  in  difficult  defecation  when  the  bowels  are  constipated. 

Location. — Varicocele  usually  affects  the  left  spermatic  plexus  in  pref- 
erence to  the  right.  This  is  explicable  by:  1.  The  lower  position  of  the  left 
testis.  2.  The  relative  acuteness  of  the  angle  formed  by  the  junction  of  the 
left  spermatic  vein  with  the  renal.  3.  The  close  proximity  of  the  left  sper- 
matic vein  to  the  sigmoid  flexure  of  the  colon  and  consequent  exposure  to 
pressure  in  constipation.  4.  The  absence  of  a  valve  in  the  left  spermatic 
vein  at  its  junction  with  the  renal  vein.  5.  The  tendency  of  men  to  stand 
upon  the  left  foot. 

The  relatively  greater  weight  of  the  column  of  blood  in  the  spermatic 
plexus,  due  to  the  fact  that  the  left  cord  and  its  accompanying  veins  are 
longer  than  the  right,  is  alone  a  sufficient  explanation  for  the  preponderance 
of  varicocele  upon  the  left  side. 

Etiology. — The  causes  of  varices  in  general  are  several.  It  is  prob- 
able that  an  inherent  lack  of  tone  of  the  venous  walls  is  the  foundation  of 
the  majority  of  cases.  This  may  be  designated  as  hereditary  or  congenital 
predisposition.  Individuals  who  are  debilitated  from  any  cause  are  most 
liable  to  the  occurrence  of  varicose  veins.  In  such  conditions  the  venous 
walls  are  lax,  flabby,  and  unresisting,  and,  inasmuch  as  the  causes  that  pro- 
duce this  condition  of  affairs  also  weaken  the  heart's  action,  there  is  a  de- 
ficiency in  the  vis  a  tergo,  which  is  so  important  in  the  propulsion  of  the  blood 
through  the  veins,  as  well  as  a  deficiency  in  the  aspirating  power  of  the  heart 
and  lungs  within  the  chest.  These  same  patients  present  a  tendency  to 
hemorrhages,  on  account  of  a  lack  of  vascular  tone;  in  a  general  way,  the 
existence  of  varices  in  patients  about  to  be  operated  upon  is  a  note  of  warn- 
ing as  regards  possible  serious  hemorrhage.  Persons  suffering  from  such 
diseases  as  purpura  and  scurvy  are  especially  liable  to  relaxed  and  dilated 
veins.  Strumous  individuals  are  also  predisposed  to  varices.  Persons  of 
indolent  habits  are  quite  apt  to  have  varices,  because  of  defective  circulation 
associated  with  the  relaxed  condition  of  the  venous  walls  produced  by  the 
general  lack  of  tone  incidental  to  insufficient  exercise.  Such  persons  who  are 
compelled  to  stand  at  their  work  for  prolonged  periods  are  peculiarly  sub- 
ject to  varicose  veins.  Certain  diseases  of  the  heart,  liver,  lungs,  and  peri- 
toneal cavity,  which  by  pressure  induce  obstruction  to  the  return-fiow  of 


ETIOLOGY    OF    YAEICOCELE. 


987 


blood  through  the  vena  cava  and  iliac  veins,  favor  the  occurrence  of  venous 
varicosities.  In  long-standing  obstruction  of  the  portal  circulation  varico- 
cele is  liable  to  occur  in  conjunction  with  hemorrhoids. 

Masturbation,  sexual  excess,  and  prolonged  venereal  excitement  with- 
out gratification  are  undoubted!}^  contributory  causes  of  varicocele  in  some 
instances.  It  is  improbable  that  these  causes,  brought  into  play  for  the  first 
time  in  a  healthy  adult,  would  produce  much  effect,  but,  occurring  as  they 
do  when  tissue  development  is  really  in  excess  as  compared  with  the  inherent 
resisting  power  of  the  various  tissues,  they  operate  very  powerfully  in  pro- 
ducing primarily  congestion  and  finally  dilation  of  the  spermatic  plexus. 


Fig.  228. — Enormous  pendulous  scrotum  from  varicocele. 
(After  Hourteleup.) 


It  will  be  found,  however,  that  in  a  large  proportion  of  cases  that  seem 
directly  attributable  to  these  causes  there  exists  a  foundation  for  the  disease 
in  the  form  of  an  inherently-defective  tone  of  the  vascular  walls,  possibly 
akin  to  the  obscure  condition  existing  in  hemophilia  so  far  as  regards  its 
hereditary  character.  Inasmuch  as  it  is  established  that  this  disease  is 
hereditary  and  to  a  certain  extent  dependent  upon  defective  arterial  con- 
tractility, it  is  logical  to  infer  that  a  similar  hereditarily  defective  tone  of 
the  venous  walls  may  exist. 

"V\Tien  associated  with  other  causes  chronic  constipation  has  an  impor- 
tant influence  in  the  production  of  varicocele;  obviously  the  pressure  of 
accumulated  feces  upon  the  spermatic  vein  produces  more  or  less  obstruc- 


988 


VAEIGOCELE. 


tion  to  the  return-circulation.  The  pressure  of  a  truss  occasionally  induces 
varicocele  as  a  comiDlication  of  hernia.  The  disease  may  be  caused  by  lifting 
or  athletic  strain  of  various  kinds.  The  author  has  seen  several  cases  of  this 
sort.  Horseback-riding  may  cause  the  disease;  varicocele  is  a  frequent  basis 
for  pension  claims' among  old  cavalrymen. 

Percival  Pott  describes  "acute  varicocele"  due  to  a  combination  of 
fatigue,  traumatism,  and  exposure  to  cold,  the  condition  being  followed  by 
complete  atrophy  of  the  testis.     These  cases  were  imdoubtedly  spermatic 


Fiff.  229. — Dissection  of  varicocele.     (After  Monod  and  Terrillon.) 


phlebitis,  from  infection  of  some  sort,  resulting  in  a  proliferation  of  con- 
nective tissue  that  permanently  occluded  the  affected  veins  and  probably 
also  the  arteries  of  the  cord. 

Varicocele  occurs  with  the  greatest  frequency  between  the  ages  of  fif- 
teen and  thirty-five,  the  period  when  all  the  faculties  of  the  body  are  at  their 
maximum  of  development  and  physical  growth  is  most  active.  It  is  also 
at  this  period  that  perverted  sexual  habits  and  hygiene  are  apt  to  develop  in 
the  form  of  sexual  excess,,  excitement  without  gratification,  or  else  masturba- 
tion. 


SYMPTOMS    OF    VAEICOCELE.  989 

Hernia  and  varicocele  are  not  infrequently  dependent  upon  the  same 
inherent  structural  weakness  of  the  inguinal  region.  Hernia  may  also  act 
as  a  direct  cause  of  varicocele  by  pressure  upon  the  cord. 

MoKBiD  Anatomy. — The  anatomic  changes  in  varicocele  chiefly  com- 
prise dilation  and  tortuosity  of  the  veins  associated  with  loss  of  elasticity 
and  contractility.  There  is  usually  more  or  less  increase  in  the  thickness  of 
the  venous  walls.  This,  however,  does  not  make  them  proportionately 
stronger,  because  of  the  fact  that  the  vessel  is  enormously  dilated,  its  walls 
being  consequently  thinner  in  proportion  to  the  weight  of  its  contents  than 
those  of  the  normal  vessels.  The  elastic  and  contractile  tissue  of  the  venous 
walls  is  destroyed,  and  replaced  by  a  low  grade  of  connective  or  fibro-con- 
nective  tissue.  Chronic  phlebitis  may  occur;,  enhancing  the  vascular  thick- 
ening. In  some  instances  concretions  (phleboliths)  are  found  within  the 
lumen  of  the  veins.  The  valves  of  the  veins  are  almost  completely  destroyed 
so  far  as  their  functionating  capacity  is  concerned.  Spots  of  fatt}''  degenera- 
tion often  exist  in  different  portions  of  the  venous  walls.  The  scrotum  is 
always  thin  and  relaxed,  its  muscular  tissue  being  greatly  weakened,  and,  as 
evidence  of  the  association  of  varicocele  with  an  inherent  deficiency  of  vas- 
cular tone,  the  scrotal  veins  are  often  enormously  dilated  and  tortuous. 

Symptoms. — The  symptoms  of  varicocele  vary  with  its  severity.  The 
patient's  attention  is  usually  first  attracted  to  the  venous  enlargement,  pro- 
ducing a  slightly  tumorous  condition  of — as  he  erroneously  supposes — ^the 
testis. 

This  enlargement  is  so  slight  in  the  majority  of  cases  that  it  is  of  no 
practical  importance,  its  principal  effect  being  a  disturbance  of  the  patient's 
psychic  status.  Individuals  who  consult  the  surgeon  regarding  the  slighter 
forms  of  varicocele  are  generally  masturbators  who  have  become  aware  of 
the  evil  effects  of  the  habit  and  under  the  stimulation  of  quack  literature  are 
practicing  most  .rigorous  introspection  and  frantically  searching  for  morbid 
effects  of  their  vicious  indulgence.  In  their  daily  genital  inspection  they 
accidentally  discover  a  slight  enlargement  of  one  or  the  other  testis,  with 
attendant  relaxation  of  the  scrotum.  Possibly  their  attention  is  for  the  first 
time  called  to  the  fact  that  one  testis  hangs  lower  than  the  other.  The  dis- 
covery of  these  things  in  combination  with  his  morbid  apprehensions  alarms 
the  patient  and  induces  him  to  seek  relief.  Only  too  often  he  consults  the 
quack,  who  finds  in  such  victims  his  most  profitable  patients,  particularly  if 
pseudospermatorrhea  or  nocturnal  emissions  co-exist,  as  is  quite  likely  to  be 
the  case.  These  slight  enlargements  of  the  spermatic  veins  are  due  to  im- 
jDerfect  sexual  hygiene  with  attendant  vascular  congestion;  they  generally 
disappear  after  normal  sexual  relations  have  been  established;  the  practi- 
tioner is  seldom  again  consulted  when  such  patients  are  physiologically 
married.  Operative  interference  in  these  cases  is  usually  unwarrantable;  it 
may,  however,  be  psychically  indicated  in  certain  exceptional  cases. 

Varicocele  in  its  more  marked  forms  is  very  easily  recognized.    It  pre- 


990  YAKICOCELE. 

sents  a  soft,  mushy  tumor  that  has  been  aptly  said  to  impart  to  the  fingers 
a  sensation  as  of  a  bundle  of  worms  within  a  sac.  The  veins  of  the  scrotum 
are  often  tortuous  and  dilated.  The  tumor  is  not  tender  upon  pressure  un- 
less phlebitis  exists.  Phleboliths  are  sometimes  to  be  detected  within  the 
cavity  of  the  veins'  by  digital  exploration. 

The  subjective  symptoms  are  both  mental  and  physical.  In  nearly  all 
well-marked  cases  there  is  considerable  psychic  disturbance  as  well  as  a  vary- 
ing degree  of  actual  physical  discomfort.  In  nearly  every  young  man  af- 
fected with  marked  varicocele  there  is  more  or  less  mental  depression  and- 
sexual  hypochondriasis  that  in  certain  instances  make  his  life  miserable.  If 
the  patient  be  sensitive,  the  physical  deformity  caused  by  the  varix  may 
prove  very  embarrassing.  In  all  cases  of  severe  varicocele  there  is  unques- 
tionably a  marked  lack  of  tone  of  the  sexual  apparatus:  pseudo-impotency, 
frequent  pollutions,  pseudospermatorrhea  and  even  true  spermatorrhea  often 
exist,  and  may  persist  even  after  a  successful  operation.  Irritability  of  the 
vesical  neck,  neuralgia  of  the  testes,  dragging  pains  along  the  spermatic 
cord,  and  pain  in  the  back  and  thighs  are  among  the  more  disagreeable 
symptoms  produced  by  the  disease.  When  the  scrotum  is  very  lax  and 
pendulous,  its  veins  being  dilated  and  tortuous,  there  may  be  considerable 
mechanic  discomfort.  Should  the  sudoriparous  secretion  of  the  relaxed 
scrotum  be  excessive,  pruritus  with  perhaps  eczema  may  exist. 

The  pain  and  mental  discomfort  incidental  to  varicocele  are  not  neces- 
sarily proportionate  to  the  severity  of  the  disease.  Some  patients  with  very 
slight  varicocele  are  profoundly  depressed  and  complain  greatly  of  reflex 
neuralgic  pains  in  the  back,  thighs,  and  testes.  In  other  cases  an  enormous 
varicocele  may  produce  no  discomfort  save  such  as  is  incidental  to  its  bulk 
and  consequent  mechanic  effects,  locomotion  being  impeded  in  some  cases. 

The  subjective  symptoms  of  varicocele  sometimes  improve  temporarily 
after  sexual  intercourse:  a  fact  that  is  therapeutically  suggestive. 

Teeatment. — Opinions  as  to  the  advisability  and  preferable  methods 
of  treatment  of  varicocele  vary  considerably.  Until  recent  years  most  sur- 
geons have  had  a  decided  leaning  toward  conservatism.  Since  aseptic  and 
antiseptic  methods,  however,  have  demonstrated  the  safety  of  operation  in 
varicocele,  various  methods  of  radical  cure  have  become  deservedly  popular. 
This  is  fortunate,  for  there  is  a  certain  proportion  of  cases  in  whom  both 
the  physical  and  mental  effects  of  the  disease  are  very  demoralizing.  Often, 
it  is  true,  the  evil  effects  of  varicocele  are  largely  psychic.  This  has  been 
urged  as  an  argument  in  favor  of  conservatism,  and  as  a  positive  contra-in- 
dication  to  all  operative  measures.  It  is  to  remembered,  however,  that 
psychopathic  conditions  occurring  in  certain  neurotic  patients  affected  by 
varicocele  are  productive  of  great  annoyance,  and  are  only  too  real  so  far  as 
the  patient's  subjective  sensations  are  concerned.  His  psychopathia  depends 
upon  an  organic  cause  that  is  intimately  associated  with  the  sexual  function: 
a  matter  of  decided  concern  to  the  average  individual,  and  especially  to  the 


TEEATMENT    OF    VAEICOCELE.  991 

type  in  whom  varicocele  is  most  frequent.  It,  therefore,  operations  for  the 
radical  cure  of  the  disease  can  be  made  practically  safe,  it  is  the  duty  of  the 
surgeon  to  offer  the  resources  of  his  art  to  sufferers  from  varicocele  just  as 
in  any  pathologic  condition  which,  although  not  immediately  dangerous  to 
life,  is  productive  of  physical  discomfort  and  mental  disquiet. 

Palliative  Treatment. — The  treatment  of  the  milder  forms  of  varicocele 
should  be  palliative.  The  application  of  cold,  electricity,  and  the  wearing 
of  a  close-fitting  suspensory  bandage  are  the  principal  local  measures  to  be 
advised.  The  principles  already  formulated  in  the  chapter  on  genito-urinary 
and  sexual  hygiene  should  be  rigidly  enforced,  and  the  patient  instructed  to 
a  certain  extent  in  sexual  physiology,  this  being  absolutely  necessary  to  keep 
the  patient  from  the  clutches  of  the  quacks.  He  should  be  informed  that 
the  affection  is  perfectly  innocuous,  and  will,  in  all  probability,  entirely 
disappear  after  marriage,  which  should  be  consummated  as  soon  as  prac- 
ticable. If  the  varicocele  be  associated  with  nocturnal  emissions  or  sper- 
matorrhea, it  may  be  necessary  to  adopt  some  of  the  therapeutic  measures 
indicated  in  such  conditions.  When  the  patient  is  inclined  to  be  hypochon- 
driac, or  suffers  from  testicular  neuralgia,  a  cold  sound  should  be  passed  into 
the  urethra  every  three  or  four  days.  The  result  of  this  simple  treatment  is 
often  surprising,  the  morale  of  the  patient  being  greatly  improved.  Such 
results  are  explicable  by  the  effect  upon  the  mind  as  well  as  the  local  phys- 
ical condition.  Constipation  requires  the  use  of  mild  laxatives.  Slothful 
habits  of  life  should  be  corrected  and  proper  exercises  advised.  If  the  pa- 
tient be  debilitated,  tonics,  such  as  iron,  strychnin,  and  the  mineral  acids, 
should  be  given.  Theoretically,  ergot  is  of  service  in  such  cases;  hamamelis 
has  also  been  indorsed  as  a  remedy  for  varicose  veins  in  general,  and  seems 
to  have  a  more  marked  action  upon  the  venous  walls  than  ergot.  It  is  worthy 
of  trial  in  varicocele  where  treatment  is  required  yet  operation  seems  inad- 
visable or  is  refused.  The  foregoing  measures  usually  relieve  the  symptoms 
produced  by  the  milder  forms  of  varicocele  and  prevent  increase  in  size  of 
the  tumor.  In  the  more  severe  cases,  however,  the  characteristic  changes 
in  the  venous  walls,  due  mainly  to  loss  of  tone  or  connective-tissue  prolifera- 
tion, go  on,  and  considerable  enlargement  of  the  spermatic  plexus  with 
its  attendant  discomfort  results.  In  the  more  marked  eases  the  resulting 
physical  deformity  may  cause  considerable  annoyance.  In  these  cases  the 
suspensory  bandage  fails  to  prevent  noticeable  deformity,  and  does  not  sat- 
isfactorily allay  the  various  disagreeable  subjective  symptoms;  its  failure 
to  relieve  the  patient's  psychic  condition  is  especially  evident,  for  in  remov- 
ing and  applying  his  bandage  he  is  made  painfully  cognizant  of  his  deform- 
ity. The  knowledge  that  he  is  unlike  other  young  men  as  regards  his  sexual 
apparatus  has  a  peculiarly  demoralizing  effect.  For  such  cases,  then,  we 
must  advise  more  effectual  means  of  relief  than  palliative  measures. 

Operative  Treatment. —The  indications  for  operation  in  varicocele  may 
be  formulated  as  follows: — 


992  YAEICOCELE. 

1.  Ver}-  large  varicocele  causing  perceptible  deformit3\ 

2.  Pain  in  the  tumor  or  obstinate  reflex  neuralgia. 

3.  Aberration  of  tlie  sexual  function. 

4.  Severe  and  obstinate  dermic  lesions  of  the  scrotum. 

5.  Interference  with  the  .patient's  occupation. 

6.  Atrophy  of  the  affected  testis. 

7.  Disease  of  the  opposite  testis. 

8.  Psychopathic  symptoms. 

9.  Desire  to  enter  public  service — military,  naval,  or  civil. 

10.  Cases  of  double  varicocele,  involving  danger  of  serious  impairment 
of  the  sexual  function.  In  such  cases  only  one  side  should  be  operated  at 
a  time;  destruction  of  the  function  of  both  organs  by  atrophy  would  be 
somewhat  embarrassing. 

11.  Complicating  hernia  or  hydrocele  when  these  conditions  are  oper- 
able and  it  seems  advisable  to  operate  them  simultaneously  with  a  radical 
ojDeration  for  the  varicocele. 

12.  Eapid  increase  in  size. 

Methods  of  Operation. — In  discussing  the  various  operations  for  vari- 
cocele it  is  not  necessary  to  do  so  in  detail;  the  raison  d'etre  of  many  of  the 
specially  devised  and  named  operations  is  apparent  only  to  the  operator. 
The  indication  in  all  operations  is  to  limit  or  suppress  the  circulation  in  the 
plexus  composing  the  varix.  For  practical  purposes  the  various  methods 
comprise:  1.  Acupressure.  2.  Subcutaneous  ligation.  3.  Open  ligation. 
4.  Ligation  with  resection  of  veins.  5.  Eesection  of  the  scrotum.  6.  Liga- 
tion with  resection  of  the  scrotum. 

1.  Acupressure. — The  employment  of  acupressure  at  the  present  day 
shows  lack  of  faith  in  modern  antisepsis.  Gradual  obliteration  of  the  veins 
by  pressure — with  or  without  ulceration — has  all  the  dangei^  of  immediate 
ligation  as  far  as  sepsis  and  trauma  are  concerned,  and,  moreover,  these  dan- 
gers are  continuously  incurred,  whether  the  process  requires  a  few  daj's  or 
several  weeks.  Lender  the  term  acupressure  are  included  all  methods  in- 
volving gradual  obliteration  of  the  veins. 

2.  Subcutaneous  Ligation. — This  is  not  an  essentially  dangerous  opera- 
tion in  skilled  hands.  Lnfortunately,  however,  the  rank  and  file  of  opera- 
tors are  not  so  skillful  as  some  of  those  who  claim  uniform  success  and  safety 
for  this  method.  Simi^le  as  the  various  methods  of  subcutaneous  ligation 
may  appear,  serious  accidents  have  occurred.  The  operation  is  done  in  the 
dark,  so  to  speak,  and  more  tissue  is  included  than  is  necessary.  A  certain 
amount  of  cellular  tissue  is  certain  to  be  included  with  the  mass  of  veins, 
and  strangulation  of  this  tissue  is  sometimes  attended  by  danger.  Again, 
the  veins  may  not  be  completely  strangulated. 

Scrotal  tissue  may  be  included  in  the  loop  of  ligature  unless  great  care 
be  taken.  The  veins  being  compressed  en  masse,  there  is  less  security  against 
secondary  hemorrhage  than  when  ligated  separately.     Scrotal  hematocele. 


TREATMENT    OF    VARICOCELE.  993 

phlebitis,  septic  infection,  thrombosis,  and  embolism  are  possibilities.  Ee- 
garding  the  latter,  however,  there  is  greater  danger  of  thrombosis  and  em- 
bolism in  gradual  occlusion  of  the  veins  than  in  cleanly,  individual  ligation. 
Subcutaneous  ligation  is  not  so  dangerous  in  this  respect  as  acupressure  and 
its  congeners,  though  more  so  than  a  neat  open  operation.  Strict  asepsis 
neutralizes  most  of  the  advantages  claimed  for  timid  and  hap-hazard  ligation 
in  the  dark.  Experienced  surgeons  have  included  the  vas  deferens  in  the 
loop  of  ligature  or  wire,  with  resultant  atrophy  of  the  testis.  Atrophy  of 
the  testis,  however,  does  not  necessarily  imply  inclusion  of  the  vas  deferens; 
ligation  of  the  spermatic  veins  alone  may  produce  it,  though  the  danger  of 
atrophy  has  been  overrated.  Severe  varicocele  is  attended  by  atrophy  of  the 
testis,  sometimes  to  a  marked  degree;  as  the  varicocele  subsides  this  degen- 
erate condition  becomes  more  and  more  apparent,  giving  a  false  impression 
of  post-operative  atrophy.  Tetanoid  symptoms  are  a  possible  result  of  in- 
clusion of  the  vas  deferens.  A  vein  with  hardened  and  thickened  walls  is 
occasionally  found  in  the  midst  of  a  varicocele;  this  may  be  mistaken  for 
the  vas  deferens. 

It  has  been  asserted  that  the  chief  clanger  of  ligation  subcutaneously 
is  inclusion  of  the  spermatic  artery,  which  is  deeply  situated  amid  the  varix. 
Ligation  of  this  arterj^,  it  is  claimed,  inevitably  causes  atrophy  of  the  testis. 
The  arteries  of  the  vas  deferens  and  cord  proper  are  sufficient,  however,  to 
preserve  the  nutrition  of  the  organ. 

W.  H.  Bennett  remarks  on  this  point  as  follows^: — 

1.  The  vas  deferens  having  been  displaced  in  the  manner  usually  adopted  in 
operations  for  varicocele,  the  spermatic  artery  does  not  accompany  it,  but  remains 
with  the  spermatic  veins. 

2.  The  division  of  the  spermatic  artery,  together  with  the  veins,  if  surgical  clean- 
liness be  observed,  is  not  only  harmless  to  the  testicles,  but  probably  aids  in  the 
ultimate  relief  of  the  affection  by  diminishing  the  pressure  of  blood  going  to  the  testis 
at  the  time  when  almost  all  the  returning  veins  are  suddenly  obliterated. 

3.  Division  of  the  vas  deferens,  spermatic  artery,  and  spermatic  veins,  entailing 
a  section  of  apparently  the  whole  cord,  is  not  necessarily  followed  by  sloughing,  or 
even  wasting  of  the  testicle,  provided  an  aseptic  condition  of  the  wound  is  maintained. 

That  severe  pain  should  sometimes  occur  after  subcutaneous  ligation  is 
not  surprising  if  the  numerous  and  sensitive  nerve-filaments  supplying  the 
involved  parts  be  taken  into  consideration.  Their  inclusion  in  the  ligature 
is  to  a  great  extent  unavoidable.  The  danger  is  reduced  to  a  minimum,  how- 
ever, by  care  in  separating  the  structures  of  the  varicocele,  so  as  to  include 
as  little  tissue  as  possible  in  the  ligature. 

Despite  the  objections  that  have  been  enumerated,  subcutaneous  liga- 
tion of  varicocele  is  simple  and,  under  aseptic  and  antiseptic  precautions, 
suiRciently  safe  and  successful  to  warrant  its  adoption  in  selected  cases.  It 
is  especially  indicated  (1)  in  mild  cases,  (2)  where  the  patient  objects  to  cut- 


^  Monograph  on  "Varicocele.' 


994  VAEICOCELE. 

ting  operations,  (3)  where  economy  of  time  must  be  considered,  and  (4)  in 
the  absence  of  facilities  for  aseptic  operating. 

In  cases  in  which  isolation  of  the  vas  deferens  is  difficult  or  doubtful, 
the  subcutaneous  operation  is  not  to  be  thought  of. 

Operation. — The  scrotum,  pubis,  and  perineum  should  be  cleanly  shaved 
and  scrubbed,  first  with  green  soap,  next  with  bichlorid  solution,  and  finally 
bathed  with  pure  alcohol.  Cocain  may  be  injected  at  the  point  of  proposed 
puncture  if  the  patient  be  sensitive.  A  few  drops  of  a  4-per-cent.  solution 
usually  suffice.  Pain  is  slight  if  the  point  of  skin-puncture  be  anesthetized. 
The  patient  should  assume  the  standing  posture  so  that  the  veins  may  be 
readily  outlined  and  isolated. 

An  aseptized  Eeverdin  or  Whitehead  needle  is  armed  with  an  aseptic 
ligature  of  medium  size  and  made  to  transfix  the  scrotum  between  the  mass 
of  veins  and  the  vas  deferens  at  about  the  Jimction  of  the  upper  with  the 
middle  third  of  the  space  between  the  inguinal  ring  and  testis.  Great  care 
should  be  taken  to  separate  the  veins  and  the  vas  deferens  so  as  to  obviate 
inclusion  of  the  latter  in  the  ligature-loop.  After  the  ligature  has  been  made 
to  traverse  the  scrotum  the  vas  deferens  should  be  carefully  sought  for  and 
its  position  internal  to  the  strand  of  ligature  accurately  determined. 


Fig.  230. — Eeverdin  needle  for  varicocele; 

The  free  end  of  the  ligature  should  now  be  drawn  out  and  secured  poste- 
riorly and  the  needle  partly  withdrawn — until  it  clears  the  veins  within  the 
scrotum.  It  is  then  made  to  traverse  the  scrotum  again,  outside  the  veins, 
its  point  being  brought  out  at  the  original  point  of  egress;  the  remaining 
end  of  the  ligature  is  drawn  out  and  removed  from  the  eye  of  the  needle. 
Finally,  the  two  ends  are  tightly  tied  and  the  mass  of  veins,  still  carrying 
the  ligature  loop,  allowed  to  drop  back  into  place. 

Another  ligature  may  be  applied  a  short  distance  below  the  first.  A 
single  ligature  is  often  enough,  but,  as  a  matter  of  precaution,  when  the  vari- 
cocele is  moderately  large  a  second  ligature  may  be  required  below  the  testis 
to  control  the  secondary  varicose  plexus  often  found  in  that  situation.  The 
material  for  ligatures  has  been  the  subject  of  some  controversy.  In  general, 
the  author  prefers  juniperized  silk.  Chromicized  catgut  is  efficient  if  asep- 
tic, but  it  is  so  often  septic  in  spite  of  all  precautions  that  silk  is  often 
preferable.  The  greater  manageability  of  the  latter  especially  commends 
it,  and  it  can  always  be  made  aseptic  by  boiling. 

The  operation  being  completed,  a  little  iodoform  collodion  should  be 
applied  to  the  punctures,  the  testis  supported  by  cotton,  gauze,  and  a  band- 
age, and  the  patient  put  to  bed  on  light  diet.    From  four  to  ten  days'  con- 


'    TEEATMENT    OF   VARICOCELE.  995 

finement  in  bed  is  generally  sufficient.    On  rising,  a  close-fitting  suspensory 
should  be  worn  for  a  time. 

.  In  lieu  of  a  sjDecial  needle  the  following  plan  may  be  followed:  After 
proper  aseptic  and  antiseptic  precautions  the  scrotum  is  gathered  up  in  the 
hand  and  transfixed  from  before  backward  with  a  small  tenotome;  the  knife 
is  then  withdrawn  and  the  scrotum  allowed  to  drop  back  in  place.  A  fine 
stiff  probe  (eyed)  threaded  with  jimiperized  silk  is  now  passed  through  the 
punctures  between  the  veins  and  vas  deferens,  and  passed  back  outside 
the  veins,  still  carrying  the  ligature,  to  emerge  at  the  point  of  original  entry 
in  front.  The  probe  is  removed  and  the  ligature  tied  and  dropped.  The 
usual  precaution  of  rest  is  taken. 

The  average  result  of  subcutaneous  ligation,  when  properly  performed, 
is  certainly  good,  a  large  proportion  of  cures  resulting.  This  compensates, 
in  a  measure,  for  certain  undesirable  features  of  the  method. 

3  and  4.  Open  Ligation  With  or  Without  Resection  of  the  Veins. — There 
is  little  difference  between  these  forms  of  open  operation,  excepting  pos- 
sibly the  additional  danger  of  sepsis  in  the  latter.  The  dangers  of  the  open 
method  are  in  a  less  degree  those  of  subcutaneous  ligation,  with  the  excep- 
tion that  inclusion  of  the  vas  deferens  cannot  occur.  If  the  open  method 
is  selected  the  point  of  exposure  should  be  as  high  up  as  possible,  and  as 
small  an  incision  made  as  it  is  practicable  to  work  through.  The  results  of 
the  open  method  thus  performed  are  excellent,  and  the  danger  under  anti- 
sepsis is  very  remote. 

5.  Resection  of  the  Scrotum. — This  is  the  safest  operation  for  varicocele, 
but  is  not  a  radical  cure  in  the  true  sense  of  the  term. 

6.  Ligation  with  Resection  of  the  Scrotum. — This  is  the  ideal  operation 
in  the  majority  of  cases  demanding  surgical  interference.  Much  depends  on 
the  method  of  performance— the  important  details,  so  far  as  danger  to  life, 
is  concerned,  affecting  chiefly  the  ligation.  Under  proper  antiseptic  precau- 
tions scrotal  amputation  does  not  complicate  or  enhance  the  dangers  of  the 
operation.  Ligation  with  resection  is  indicated  where  the  varix  is  large  and 
the  scrotum  very  lax  and  pendulous.  The  removal  of  the  latter  affords  the 
best  prophylaxis  against  recurrence  of  the  varix.  The  results  are  likely  to 
be  better  than  those  attained  by  any  of  the  other  methods. 

The  author's  early  experience  with  simple  scrotal  resection  appeared 
to  justify  the  claims  of  certain  of  its  ardent  advocates.  Wider  experience 
and  observation  have,  however,  brought  the  conviction  that  too  much  has 
been  claimed  for  the  operation.  To  be  sure,  as  some  of  its  advocates  have 
claimed,  it  makes  little  difference  if  the  operation  is  again  necessary  after 
a  lapse  of  years,  the  method  being  perfectly  safe;  but  this  is  begging  the 
question  so  far  as  a  radical  cure  is  concerned. 

In  very  large  varicocele  the  changes  in  the  venous  walls  are  such  that 
pressure  and  support  alone  are  insufficient  to  secure  restoration  of  their 
natural  consistency  and  caliber,  even  though  the  pressure  be  made  firm 


996 


VARICOCELE. 


and  continuous.  There  is  little  elasticity  in  the  remaining  portion  of  the 
scrotum^  and  the  tone  of  the  part  is  apt  to  remain  as  impaired  as  before 
the  operation — the  same  constitutional  conditions  prevailing.  Stretching 
and  relaxation  of  the  "natural  suspensory,"  or  scrotum,  will  recur  sooner 
or  later  in  the  majority  of  severe  cases.  The  varicocele  may  not  be  so  severe 
as  before  the  operation,  and  the  more  urgent  symptoms  may  be  relieved,  but 
there  is  nothing  edifying  in  the  spectacle  of  a  good-sized  varix  a  few  years, 
or  perhaps  months,  after  a  so-called  radical  cure.  The  subjective  symptoms 
do  not  always  recur  pari  passu  with  a  return  of  the  varix,  it  is  true;  but  a 
"radical  cure"  is  under  discussion  and  hair-splitting  is  unnecessary.  The 
patient  is  apt  to  forget  the  original  subjective  symptoms  and  estimate  the 
value  of  the  operation  by  the  ocular  and  objective  evidence  at  his  command. 


Fig.  231.- — Large  varicocele,  seven  years  after  ablation  of  scrotum, 
showing  recurrence.      (Author's  case.) 


In  moderate  varicoceles  and  in  quite  young  subjects  the  scrotal  tissues 
retain  a  certain  degree  of  consistency  and  elasticity,  and  the  veins  do  not 
entirely  lose  their  normal  tone.  Under  these  circumstances  simple  scrotal 
resection  is  best.  The  patient  had  better  submit  to  this  operation  than  be 
permanently  annoyed  by  a  suspensory.  It  is  safe,  when  properly  performed, 
and  gives  an  excellent  result. 

The  details  of  the  operation  of  simple  scrotal  resection  follow  in  the 
description  of  Avhat  the  author  has  taken  the  liberty  of  terming  the  ideal 
operation  for  varicocele. 

Operation. — The  bowels  having  been  emptied  hj  a  saline  or  castor  oil, — 
the  latter  being  perhaps  preferable, — the  scrotum,  pubes,  and  thighs  are 


TEEATMENT    OF    VARICOCELE. 


997 


shaved  and  thoroughly  scrubbed  with  green  soap  and  bichlorid  solution  1 
to  3000  and  then  bathed  with  a  bichlorid  solution  1  to  1000,  followed  by 
alcohol. 

This  completed,  the  patient  is  anesthetized,  during  which  process  the 
scrotum  is  wrapped  in  a  towel  wet  with  the  bichlorid  solution.  The  opera- 
tor's hands  should  be  prepared  as  carefully  as  for  a  laparotomy.  The  instru- 
ments are  aseptized  by  boiling  water. 

An  incision  an  inch  to  an  inch  and  a  half  in  length  is  made,  beginning 
Just  below  the  external  abdominal  ring  parallel  with  the  spermatic  cord. 
This  is  carried  down  until  the  cord  and  its  accompanying  veins  are  exposed. 
The  number  of  veins  varies;  they  are  here  quite  straight  and  when  emptied 


Fig.  232. — Ablation  of  the  scrotum  with  Horteloup's  clamp. 
(After  Wickham.) 


of  blood  quite  small.  The  cord  and  veins  are  hooked  out  of  the  wound  with 
an  aneurism-needle.  The  veins  are  now  separated  and  each  ligated  with  a 
single  ligature  of  chromicized  catgut  of  medium  size;  the  ligatures  are  cut 
short  and  the  veins  and  cord  dropped  back  in  place.  If  there  is  any  diffi- 
culty in  reposition  of  the  cord  it  is  readily  overcome  by  traction  on  the  tes- 
ticle. If  the  varicocele  be  large,  two  sets  of  ligatures  may  be  used,  one  above 
and  one  below.  It  may  be  well,  also,  to  shorten  the  cord  by  leaving  several 
ends  of  ligature  above  and  below  and  tying  them  together,  thus  looping  up 
and  abbreviating  the  cord.  The  wound  is  now  irrigated  and  thoroughly 
dried  with  gauze  sponges.  Several  fine  stitches  of  silk-worm  gut  are  now 
inserted  and  the  wound  closed  and  dusted  with  iodoform.     During  the  re- 


998 


VAEICOCELE. 


mainder  of  the  oiDeration  the  wound,  should  be  compressed  with  antiseptic 
ganze  by  an  attendant. 

The  next  step  is  the  application  of  the  clamp.  Care  should  be  taken 
to  divide  each  side  of  the  scrotum  equally,  and  to  include  sufficient  tissue 
in  the  clamp.  It  is  well-nigh  impossible  to  remove  too  much.  The  author 
has  operated  in  cases  in  which  on  removal  of  the  clamp  after  scrotal  excision 
so  little  tissue  was  left  that  there  was  extreme  difficulty  in  covering  in  the 
testes,  yet  the  new  scrotum  proved  sufficient. 

It  is  an  excellent  plan  to  insert  a  few  harelip-pins  beneath  the  lower  bor- 
der of  the  clamp  before  cutting  away  the  scrotum,  as  the  dartos  is  very  elas- 
tic, and  is  likely  to  retract  so  that  there  is  too  little  room  for  the  sutures. 

The  point  of  election  having  been  determined  upon,  the  redundant  tis- 
sue is  quickly  cut  away  along  the  face  of  the  clamp  with  either  scissors  or 
knife.  Silk-worm-gut  sutures  should  be  used,  and  may  be  inserted  either 
before  or  after  the  excision,  but  always  before  removing  the  clamp.  There 
should  be  as  little  delay  as  possible,  as  the  prolonged  pressure  of  the  clamp 


Fig.  233. — Henry's  clamp  for  scrotal  resection. 


produces  more  or  less  bruising  of  the  loose  scrotal  tissues  that  is  not  con- 
ducive to  prompt  union.  If  tension  is  great,  three  or  four  harelip-pins  may 
be  used  to  reinforce  the  gut.  They  should  be  inserted  at  equally-divided 
intervals  and  the  sutures  interposed  in  sufficient  number  to  prevent  gaping 
and  maintain  accurate  apposition. 

The  secondary  blade  of  the  clamp  having  been  removed,  the  sutures 
are  secured  with  snap-forceps  and  the  main  clamp  removed.  If  the  sutures 
be  tied  before  removal  of  the  clamp,  the  surgeon  may  have  to  reopen  the 
wound  to  ligate  some  spouting  vessel.  Vessels  should  be  twisted  where  pos- 
sible, or  traversed  by  a  suture.  An  assistant  must  press  back  the  testes,  else 
they  will  prove  embarrassing. 

All  hemorrhage  having  been  checked,  the  wound  is  permanently  closed. 
Too  much  care  cannot  be  taken  in  checking  hemorrhage,  as  there  is  an 
especial  tendency  to  venous  oozing.  The  formation  of  a  clot  beneath  the 
wound  will  not  only  prove  a  source  of  septic  danger,  but  will  prevent  speedy 
union.     There  is  also  the  danger  of  serious  passive  hemorrhage.     To  one 


TEEATMENT    OF    VARICOCELE.  999 

unfamiliar  with  operations  about  these  parts  the  tendency  to  prolonged 
oozing  is  peculiar;  it  may  persist  for  several  days  after  a  most  careful  opera- 
tion for  varicocele. 

Having  dried  and  closed  the  wound,  if  should  be  dusted  with  iodoform 
and  a  piece  of  oiled  silk  or  protective  laid  along  the  edges  to  prevent  adhe- 
sion of  the  subsequent  dressings.  A  quantity  of  borated  cotton  and  anti- 
septic gauze  in  which  a  hole  has  been  cut  for  the  penis  is  now  applied  and 
the  whole  secured  by  a  three-tailed  bandage  secured  at  the  waist.  A  light 
diet  should  be  advised,  and  no  attempt  made  to  move  the  bowels  for  four 
or  five  days.  When  a  movement  does  occur,  the  parts  should  be  carefully 
supported  and  a  bed-pan  used. 

The  sutures  should  not  be  removed  for  a  week  or  ten  days,  else  gaping 
of  the  wound  will  quite  likely  occur,  so  extreme  is  the  tension  when  the 
operation  is  properly  performed. 

The  patient  may  be  allowed  to  get  up  in  two  weeks,  if  no  complications 
arise. 


APPENDIX. 


The  author  has  avoided  foot-notes  so  far  as  possible,  and  has  made 
very  few  references  in  the  text  to  literature  of  his  own  bearing  upon  certain 
views  herein  set  forth.  Inasmuch  as  he  has  ventured  to  touch  upon  cer- 
tain points  that  have  been  elsewhere  presented  in  extenso,  it  has  seemed 
fitting  to  refer  to  the  most  important  of  the  various  special  articles  he  has 
published  treating  of  the  subjects  presented  in  this  volume. 

"Injuries  of  the  Lrethra."  Medical  and  Surgical  Eeporter,  Philadelphia,  May, 
1887. 

"Eecurrent  Syphilitic  Bubo."    Medical  Era,  October,  1887. 

"Treatment  of  Syphilis."     The  Physician  and  Surgeon,  September,  1887. 

"Treatment  of  Chancroids."    Philadelphia  Medical  Eegister,  October,  1887. 

"Passive  Congestion  of  the  Prostate  and  its  Relation  to  Hematuria."  Medical 
Era,  September,  1887. 

"Reflex  Urethral  Xeuroses."    Western  Medical  Reporter,  December,  1887. 

"Lectures  on  Syphilis."    Western  Medical  Reporter,  January  to  July,  1884. 

"Syphilis  in  its  Relations  to  Dental  and  Oral  Surgery."  Journal  of  the  Ameri- 
can Medical  Association,  June,  1886. 

"Urine  or  Urethral  Fever."     Philadelphia  Medical  Register,  April,  1888. 

"Varicocele."    Medical  Times  and  Register,  August  31,  September  6,  1889. 

"Aberrant  Sexual  Differentiation."  St.  Louis  Weekly  Medical  Review,  November 
2,  1889. 

"Sexual  Perversion."  Philadelphia  Medical  and  Surgical  Reporter,  September 
7  and  18,  1889. 

"The  Local  Management  of  Syphilitic  Phenomena."  Cincinnati  Lancet-Clinic, 
October  26,  1889. 

"Essay  on  Gonorrhea."     Medical  Age,  October  10,  1889. 

"Malignant  Transformation  of  Syphiloma  of  the  Tongue;  Amputation  by  the 
Galvanocautery."     Medical  Record,  October  26,  1889. 

"Evolution  of  the  Local  Venereal  Diseases."  New  York  Medical  Record,  volume 
xxxvii,  No.  2. 

"Herpes  Progenitalis."     Philadelphia  Medical  News,  April,  1890, 

"Gonorrhea  in  Women."     Medical  Age,  January,  1890. 

"Trophoneurosis  in  its  Relations  to  the  Phenomena  of  Syphilis."  Transactions 
of  the  Southern  Surgical  and  Gynecological  Association,  1890. 

"Evolution  of  the  Local  Venereal  Diseases."    Medical  Age,  February  10,  1890. 

"Evolution  of  the  Local  Venereal  Diseases."  St.  Louis  Medical  Review,  February 
22,  1890. 

"Bubo."    Virginia  Medical  Monthly,  March,  1890. 

"Trophoneurosis  in  its  Relations  to  Dental  and  Oral  Surgery."  Journal  of  the 
American  Medical  Association,  June  21,  1889. 

"Observations  on  Urethral  Stricture."  Chicago  Medical  Recorder,  November, 
1891. 

(1000) 


APPENDIX.  1001 

"Syphilis  in  its  Eelation  to  the  Repair  of  Surgical  Injuries."  Philadelphia 
Medical  and  Surgical  Reporter,  November  12,  1891. 

"The  General  Management  of  Syphilis."    Medical  Fortnightly,  January,  1892. 

"Pulsatilla  in  Inflammation  of  the  Testis."  Chicago  Journal  and  Examiner, 
March,  1882. 

"The  jSTursing  of  Syphilitic  Infants."    Western  Medical  Reporter,  July,  1882. 

"The  Treatment  of  Bubo."     Chicago  Medical  Journal  and  Examiner,  1883. 

"The  Treatment  of  Varicocele."  Chicago  Medical  Journal  and  Examiner, 
September,  1883. 

"Reflex  Genito-Urinary  Neuroses."  Philadelphia  Medical  and  Surgical  Reporter, 
August  13,  1892. 

"A  Remarkable  Case  of  Circinate  Syphilide  with  Palmar  Psoriasis."  Philadelphia 
Medical  News,  August  12,  1892. 

"Chronic  Ulceration  and  Induration  of  the  Female  Genitalia."  Transactions  of 
the  Chicago  Academy  of  Medicine,   1892. 

"The  Present  Status  of  the  Surgery  of  the  Prostate."  International  Journal  of 
Surgery,  September,  1893. 

"Surgical  Relations  of  Urinalysis."     Medical  Age,  August  25,  1892. 

"Irrigation  of  the  Deep  Urethra  and  Bladder  Without  Catheter  or  Tube."  Jour- 
nal of  Cutaneous  and  Genito-Urinary  Diseases,  September,   1892. 

"Irrigation  of  the  Deep  Urethra  and  Bladder  Without  Catheter  or  Tube." 
International  Medical  Magazine,  September,  1893. 

"Syphilis  in  the  Lower  Animals."    North  American  Practitioner,  March,  1893. 

"Oil  of  Eucalyptus  as  a  Urinary  Antiseptic."  Journal  of  Cutaneous  and  Venereal 
Diseases,  July,  1893. 

"Hemorrhagic  Emissions."  Journal  of  Cutaneous  and  Venereal  Diseases,  Feb- 
ruary, 1894. 

"The  Germ  of  Chancroid."    International  Medical  Magazine,  December,  1895. 

"Analysis  of  So-Called  Urethral  Fever."  Chicago  Medical  Recorder,  December, 
1892. 

"Modern  Bacteriologic  Research  in  Its  Relations  to  Genito-Urinary  Surgery." 
International  Medical  Magazine,  June,  1893,  and  Transactions  of  the  Southern 
Surgical  and  Gynecologic  Association,  1893. 

"The  Etiology  of  Prostatic  Hypertrophy."  Medical  and  Surgical  Reporter,  May 
13,  1893. 

"Remarks  on  Stricture  of  Large  Caliber."  Chicago  Medical  Recorder,  September, 
1893. 

"The  Trophoneurotic  Element  in  Some  of  the  Phenomena  of  Syphilis,  With 
Especial  Reference  to  Herpes  Progenitalis."     Medical  Age,  December  26,  1893. 

"Remarks  on  the  Relation  of  Residual  Urine  to  Vesical  Irritation,  Especially  in 
Prostatiques."     International  Medical  Magazine,  Sejatember,  1894. 

"Nervous  Disease  in  Early  Syphilis."  Journal  of  the  American  Medical  Associa- 
tion, March,  1895. 

"The  Relation  of  Glycosui'ia  to  Reflex  Irritation  of  the  Genito-Urinary  Organs." 
Western  Medical  Review,  October,  1897. 

"Sterility  in  the  Male."    Medical  Mirror,  February  and  March,  1897. 

"Aberrations  of  the  Sexual  Function  in  the  Male."  Tri-State  Medical  Journal, 
May  to  October,  1897. 

"Infection  by  the  Urethral  Sound."     Medical  News,  June  12,  1897. 

"A  Beswme  of  Experience  with  Internal  Anterior  Urethrotomy."  Medical  News, 
March  4,   1898. 


1002  APPENDIX. 

MONOGRAPHS. 

"Lectures  on  Syphilis."     12mo.    A.  M.  Wood  and  Co.,  Chicago,  1884. 

"Gonorrhea  and  Urethritis."  12mo.  George  S.  Davis  Publishing  Co.,  Detroit, 
1892. 

"Stricture  of  the  Urethra."    8vo.     W.  T.  Keener  Co.,  1892. 

"Varicocele."     8vo.     W.  T.  Keener  Co.,  1892. 

"Diseases  of  the  Urethra  and  Prostate."  Twentieth  Century  Medicine.  William 
Wood  and  Co.,  1895. 

"Diseases  of  the  Urethra."  American  Text-book  of  Genito-Urinary  and  Skin 
Diseases.    W.  B.  Saunders,  Philadelphia,  1898. 


I^^DEX. 


Abscess,  periurethral,  complicating  strict- 
ure, 256. 
symptoms  of,  256. 
treatment  of,  257. 

Abscesses  discharging  into  the  genito- 
urinary tract,  clinical  features  of 
the   urine  in,  30. 

Absorption,  septic,  from  genito-urinary 
tract,  47. 

Aceelerator-urinse  muscles,  95. 

Acetonemia,  25. 

Acne,   iDcnile,   84. 

treatment  of,  84. 

Adenitis,  venereal,  308. 

Adenopathy,  general  syphilitic,  378. 
primary  syphilitic,  373. 

Albumin  in  the  urine,  23. 

Alcohol,  effect  of,  in  genito-urinary  and 
venereal  diseases,  4. 

Anesthetic,  danger  of,  in  genito-urinary 
operations,  62. 

Antisepsis,  urinary,  2. 

Arteries,  helicine,   70. 

Aspermia,  595. 

Aspermism,  595. 
causes  of,  5y5. 
treatment  of,  596. 

Aubert's  experiments  with  chaneroidic 
virus,  317. 

Autogenesis,  57. 

Bacteriology,  relation  of,  to  genito-urinary 

disease,  48. 
Balanitis,  83. 

ti-eatment  of,  84. 
Baruria,   12. 

Bilateral  section  for  stone,  824. 
Bilharzia  hematobia,  35. 
Bladder,  anatomy  of  the,  732. 
carcinoma  of  the,  763. 
diagnosis  of,  764. 
symptoms  of,  764. 
clinical  features  of  the  iirine  in  injuries 

of  the,  27. 
exstrophy  of  the,  737. 

treatment  of,  738. 
fibroma  of  the,  761. 
fibromyoma  of  the,  761. 
foreign  bodies  in  the,  737. 
gangrene  of  the,  754. 
hyperesthesia  of  the,  830. 
hypertrophy  and  atrophy  of  the,  755. 

treatment  of,  755. 
irritable,  830. 
myoma  of  the,  761. 
neoplasms  of  the,  757. 
rupture  of  the,  733. 
etiology  of.  733. 
incidental  to  stricture,  256. 
location  and  extent  of,  734. 


Bladder,  rupture   of,  morbid  anatomv  of, 
734. 
symptoms  of,  734. 
treatment  of,  735. 
Blood  in  the  urine,  24. 
Blood-corpuscles  in  the  urine,  26. 
Bougies,  224. 

Bowels,  condition  of,  as  influencing  genito- 
urinary and  venereal  diseases,  4. 
Bubo,  308. 

diagnosis  of,  i521. 

forms  of,  309. 

in  gonorrhea,   134. 

location  of,  310. 

phagedenic,  315. 

recurrent  syphilitic,  319. 

symptoms  of,  313. 

time  of  appearance  of,  312. 

treatment  of,  322. 

virulent,  314. 
Buck's  fascia,  71. 

Calculi,  consistency  and  form  of,  784. 
location  of,  783. 
number  of,  783. 
size  and  weight  of,  783. 
stiucture  of,   781. 
Calculus,  renal,  851. 
causes  of,  851. 
morbid  anatomy  of,  859. 
symptoms  of,  852. 
treatment  of,  859. 
vesical,  779. 

dangers  of  exploration  for,  789. 
diagnosis  of,  786. 
etiology  of,  779. 
frequency  of,  780. 

information  to  be  gained  by  explora- 
tion for,  788. 
morbid  anatomy  of,  785. 
prognosis  of,  790. 
symptoms  of,  785. 
treatment  of,  790. 
Cancer  of  the  penis,  76. 
chimney-sweeps',   920. 
Cannula,  shirted,  249. 
Castration,  984. 
Casts  in  the  urine,  26. 
Catarrh,  chronic,  of  the  neck  of  the  blad- 
der, clinical  features  of  the  urine 
in,  28. 
Caustics    in     the     treatment,    of    organic 

stricture,  214. 
Cavernositis,  treatment  of,  75. 
Chancre,  348. 

and    chancroid,    comparative    frequency 

of,  360. 
as  a  clinical  entity,  varieties  of,  368. 
atypic  induration  in,  355. 
cicatrix  of,  357. 

(1003) 


1004 


INDEX. 


Chancre,  complications  of,  369. 

duration  of,  367. 

excision  of,  372. 

extent  of  induration  in,  355. 

inoeulability  of,  357. 

loss  of  tissue  in,  354. 

mixed,  370. 

secretion  of,  357. 

treatment  of,  371. 
Chancres,  number  of,  367. 
Chancroid,  265. 

characteristics  of  the  ulcer  of,  283. 

chronic,  diagnosis  of.  297. 

cicatrix  of,  284. 

clinical  histoiy  of,  281. 

complications  of,  286. 

diagnosis  of,  293. 

duration  of,  285. 

extent  of,  285. 

forms  of,  281. 

inflammation  complicating,  286. 

location  of,  279. 

methods  of  infection  with,  277. 

number  of  sores,  285. 

origin  of,  267. 

prognosis  of,  284,  298. 

prophylaxis  of,  299. 

relative  frequency  of,  276. 

surgical  treatment  of,  301. 

the  germ  of,  266. 

transmissibility  to  animals  of,  275. 

treatment  of,  299. 

typic  course  of,  283. 
["hancroidic  infection,  peculiarities  of,  275. 
}hordee,  129. 

severe,  and  urethral  hemorrhage,  treat- 
ment of,  160. 
;;hyle  in  the  urine,  25. 
^hyluria,  25. 
circumcision,  81. 
l^oitus,  unphysiologic,  563. 
}olic,  nephritic,  860. 
compressor-urethrae  muscles,  95. 
Corona  glandis,  70. 
Corpora  cavernosa.  69,  70. 

chronic  inflammation  of,  74. 
simple   acute    inflammation   of,    74. 
!!orpus  innominatum,  937. 

spongiosum,  69,  70. 

inflammation  of  the,  76. 
the  bulb  of  the,  70,  71. 
"owperitis,  131. 

symptoms  of,  131. 

treatment  of,  161. 
Cryptorchidism,  921. 
Cystitis,  739. 

acute,  739. 

etiology  of,  739. 
morbid  anatomy  of,  742. 
symptoms  of;  743. 
treatment  of,  744. 

chronic,  745. 

diagnosis  of,  749. 
fomis  of,  747. 
morbid  anatomy  of,  748. 
symptoms  of,  748. 


Cystitis,  chronic,  treatment  of,  749. 

due  to  instrumentation  of  the  urethra, 

236. 
in  the  female,  753. 

treatment   of,  753. 
without  catarrn,  830. 

Diathesis,  the  oxalic  acid,  777. 
treatment  ot,  778. 
the  phosphatic,  778. 
treatment  of,  779 
the  uric  acid,  or  lithic,  777. 
treatment  of,   777. 
Diet,  influence   of,  in  reducing  acidity  of 

urine,   3. 
Dilation,     accidents     ana     morbid     effects 

sometimes  incidental  to,  232. 
Divulsion  of  stricture,  237. 
Divulsors,  237. 

Echinococci,  884. 
Elephantiasis  scroti,  920. 
symptoms  of,  920. 
treatment  of,  920. 
Endoscope,  154. 
Endoscopy  in  urethritis,  154. 
Epididymis,  916. 

chronic  induration  of  the,  972. 

syphiloma  of  the,  969. 
Epididymitis,  946. 

due  to  instrumentation  of  the  urethra, 
237. 

duration  of,  957. 

etiology   of,  947. 

frequency  of,  956. 

morbid  anatomy  of,  952. 

prognosis  of,  958. 

pseudotubercular,  972. 

symptoms  of,  956. 

time  of  onset  of,  954. 

treatment  of,  959. 
Epispadias,  99,  105. 

Dolbeau's  operation  for,  105. 

Thiersch's  operation  for,  106. 
Epithelium  in  the  urine,  26. 
Erysipelas,  phlegmonous,  of  the  penis,  90. 
symptoms  of,  90. 
treatment  of,  91. 
Expulsion  of  semen,  mechanism  of,  71. 

of  urine,  mechanism  of,  71. 

False  passages  caused  by  instrumentation. 
234. 
symptoms  of,  234. 
complicating  stricture,  249. 
treatment   of,  249. 
Fatty  matter  in  the  urine,  25. 
Fever,  septemic,   of  genito-urinary   origin, 
61. 
urinary,  or  urethral,  54. 
mixed  form  of,  62. 
nervous  form  of,  60. 
rarity  of,  in  women,  66. 
traumatic  form  of,  60. 
treatment  of,  63. 
Fibrin  in  the  urine,  25. 


INDEX. 


1005 


Fistulas,   urethral,   complicating   stricture, 
257. 
treatment  of,  257. 
Folliculitis,   129. 

treatment  of,  160. 
Frenum  preputii,  72. 

Gangrene  complicating  chancroid,  288. 
Genito-urinarv  infections,  the  bacteriologic 

relations  of,  4(3. 
Glandulse  odoriferse,  71. 
Glans  penis,  7u. 
Gleet,  150. 
Glycosuria  as  a  symptom  of  genito-urinary 

disease,  21. 
Gonococcus,  122. 

Gonorrhea    (see   "urethritis"),   116. 
in  the  female,  163. 

symptoms  and  course  of,  170. 
treatment  of,   170. 
Gonorrheal  infection,  latent,  167. 
rheumatism,  131. 
symptoms  of,  132. 
treatment  of,  162. 
varieties  of,  133. 
Gummy  infiltration,  417. 

Hematuria,  34. 

appearance  of  the  urine  in,  34. 

as  the  first  symptom  of  prostato-vesical 

tuberculosis,  44. 
diagnosis  of,  34. 
etiology  of,  35. 
idiopathic,  38. 

quantity  of  blood  present  in,  34. 
renal,  without  lesion,  39. 
significant  of  precancerous  stage  of  ma- 
lignant disease,  44. 
simple,  34. 
treatment  of,  44. 
varieties  of,  34. 
Hemoglobinuria,  34. 

Hemorrhage   due   to   introduction   of   ure- 
thral instruments,  233. 
urinary,  from  prostatic  congestion,  38. 
from  prostatic  disease,  36. 
from  renal  disease,  36. 
from  visceral  disease,  36. 
the    determination    of   the    source    of, 
36. 
Hermaphroditism,  100,  515. 
Herpes  progenitalis,  84. 
diagnosis  of,  85. 
differentiation  of,  86. 
etiology  of,  85. 
ti-eatment  of,  88. 
Hutchinson's  teeth,  466. 
Hydatid  fremitus,  884. 
Hydatid  of  Morgagni,  938. 
Hydrocele,  928. 
congenital,  935. 
diagnosis  of,  936. 
treatment  of,  936. 
diagnosis  of,  930. 
encysted,  928. 
etiology  of,  928. 


Hydrocele,  morbid  anatomy  of,  928. 

of  the  spermatic  cord,  938. 
treatment  of,  939. 

spermatic,  938. 

treatment  of,  931. 

true,  928. 
Hygiene  of  urinary  and  sexual  organs,  1. 
Hypospadias,  99,  101. 

treatment  of,  102. 

Duplay's  ojDeration  for,  103. 

Impotence  in  the  male,  575. 

classification  of,  575. 

etiology  of  true,  583. 

pseudo-impotence,   576. 

treatment  of,  586. 

true,  583. 
Infection,  ascending  and  descending,  48. 

genito-urinarv,   due    to   the   gonococcus, 
50. 
Infections,    genito-urinary,    evolution    of, 
52. 

secondary,   of  urinary   origin,   46. 

urinary,  multi2:)licity  of  germs  in,  50. 
lodin  eruptions,  496. 
lodism,  495. 

Kidney,  cancer  of  the,  891. 

diagnosis  of,  893. 

etiology  of,  892. 

symptoms  of,  894. 

treatment  of,  900. 
clinical  features  of  the  urine  in  injuries 

of  the,  27. 
congenital  absence  of,  843. 
cortical  portion  of  the,  842. 
curetting  the,  904. 
floating,  846. 
glomeruli  of  the,  842. 
horseshoe,  844. 
hydatid  disease  of  the,  883. 
symptoms  of,  884. 
treatment  of,  885. 

results   of,  884. 
malformations    and    anomalies    of    the, 

843. 
malignant  neoplasms  of  the,  891. 
Malpignian  bodies  of  the,  842. 
medullary  portion  of  the,  842. 
movable,  846. 

diagnosis  of,  848. 

etiology  of,  846. 

symptoms  of,  847. 

treatment  of,  849. 
operations  upon  the,  902. 
pelvis  of  the,  842. 
pyramids  of  the,  842. 
sarcoma  of  the,  893. 
stone  in  the,  851. 
surgical  anatomy  of  the,  842. 

clinical  features  of  the  urine  in,  31. 
trauma  of  the,  844. 

prognosis  of,  845. 

symptoms  of,  844. 

treatment  of,  845. 
Kidneys,  superaumerary,  843. 


1006 


INDEX. 


Leucoplasia,  post-syphilitic,  446. 

treatment  of,  504. 
Lithemia,  12. 
Litholapaxy,  793. 
accidents  during,  803. 
for  children,  809. 
operation  of,  795. 
technic  of.  794. 
Lithotomy,  806. 
causes  of  death  incidental  to,  821. 
history  of,  810. 
indications  for,  807. 

in  children,  807. 
lateral,  Cheselden's  operation  of,  811. 
perineal,  dangers  of,  819. 

mortality  following,  821. 
suprapubic,  824. 

operation  of,  825. 
varieties  of,  807. 
Lithotrity  and  litholapaxy,  793. 
Lithotrity,  history  of,  793. 

perineal,  805. 
Lymphangitis    of   the    integument    of   the 
penis,  89. 
treatment  of,  90. 
Lymph-scrotum,  920. 

Marriage   as   a   remedy   for   sexual   irrita- 
bility, 8. 
Masturbation,  547. 

causes  of,  549. 

due  to  phimosis,  80. 

relation   of,  to  insanity  and  imbecility, 
557. 

results  of,  555. 

symptoms  of,  554. 

treatment  of,  563. 
Meatotomy,  207. 

hemorrhage  following,  208. 
Meatus  urinarius,  70. 
Median  perineal  section  for  stone,  822. 

operation  of,  823. 
Mediastinum  testis,  917. 
Medio-lateral  section  for  stone,  824. 
Mercurial   depression,  489. 
Mercury,  effects  of,  upon  the  blood,  481. 
Monorchidism,  921. 
Mucus  in  the  urine,  25. 
Miiller,  duct  of,  938. 
Myalgia  in  gonorrhea,  134. 

Neoplastic  formations  in  the  genito-urinary 
tract,     clinical     features     of     the 
ui-ine  in,  30. 
Nephralgia,  850. 

treatment  of,  851. 
Nephrectomy,  905. 
Nephritic  colic,  860. 

treatment  of,  861. 
Nephritis,   acute,   clinical   features   of   the 
urine  in,  31. 

caseous,  887. 

of  surgical  origin,  872. 

subacute,  of  surgical  origin,  875. 

symptoms  of,  875. 

syphilitic   (so  called),  902. 


Nephritis,  treatment  of,  877. 
Nephrolithotomy,  903. 
Nephrophthisis,  887. 
Nephrorrhaphy,  90o. 
Nephrotomy,  902. 
Neuralgia  of  the  vesical  neck,  830. 
Neuroses  of  the  bladder,  830. 

from  stricture,  204. 

reflex,  of  prostatic  origin,  633. 
Noeggerath's  theory,  164. 
Nymphomania,  545. 

treatment  of,  547. 

Onanism,  563. 
Orchitis,  941. 

etiology  of,  941. 

symptoms  of,  943. 

syphilitic,  970. 

treatment  of,  945. 
Orgasm,  nature  of  the  venereal,  553. 
Oxalemia,  19. 

Oxalic  acid  in  the  urine,  19. 
Oxaluria,  19. 

Pampiniform  plexus.  916. 

Papillomata,  genital,  92. 

treatment  of,  92. 

simple,  complicating  chancroid,  293. 
Paraphimosis,  80. 

treatment  of,  82. 
Parovarium,  937. 
Pediculus  pubis,  919. 
Penis,  anatomy  and  physiology  of,  69. 

anomalous  formation  of,  73. 

arteries  of,  71. 

congenital  absence  of,  73. 

dangers  of  injuries  to,  73. 

diseases  of  the  body  of  the,  74. 

double,   73. 

eczema  of  the,  84. 
treatment   of,    84. 

injuries  of  the,  73. 
treatment  of,  74. 

integument  of,  72. 

lymphatics  of,  71. 

nerves  of  the,  71. 

new  growths  of  the,  76. 
treatment  of,  78. 

ossification  of  the,  74. 

Avounds  of  the,  73. 
Perineal  section,  244. 
with  a  guide,  244. 
without  a  guide,  246. 
Perineuritis  in  gonorrhea,  134. 
Phagedena  complicating  chancroid,  289. 

etiology  of,  292. 
Phimosis,  80. 

and     paraphimosis     complicating    chan- 
croid. 288. 

treatment  of,  81. 
Phlegmon,  periurethral,   130,   160. 
Phosphoric  acid  in  the  urine,  20. 
Posthitis,  83. 

treatment  of,  84. 
Prostate,  abscess  of  the,  651. 

anatomy  and  physiology  of  the,  624. 


INDEX. 


1007 


Prostate,  anomalies  of  development  of  the, 
630. 
calculus  of  the,  683. 
cancer  of  the,  681. 

diagnosis  of,  683. 

forms  of,  682. 

symptoms  of,  682. 

treatment  of,  683. 
circulatory  supply  of  the,  628. 
clinical  features  of  the  urine  in  injuries 

of  the,  27. 
enlarged,   technic   of   operation    for    the 

relief  of,  720. 
hyperemia  of  the,  637. 

etiology  of,  637. 

symptoms  of,  640. 

treatment  of,  641. 
hypertrophied,  dimensions  of,  697. 
hypertrophy  of  the,  686. 

castration  for,  723. 

diagnosis  of,  705. 

etiology  of,  686. 

frequency  of,  698. 

morbid  anatomy  of,  698. 

symptoms  of,  701. 

treatment  of,  707. 

varieties  of,  692. 
injuries  of  the,  631. 

symptoms  of,  632. 

treatment  of,  633. 
muscular  fibres  of,  628. 
nerve-supply  of,  628. 
neuroses  of,  633. 
sexual  function  of,  629. 
structure  of,  627. 
tuberculosis  of  the,  675. 

morbid  anatomy  of,  676. 

symptoms  and  diagnosis  of,  679. 

treatment  of,  681. 

varieties  of,  675. 
Prostatectomy,  722. 
Prostatic  calculi,  629. 
ducts,  625. 
neuralgia  and  hyperesthesia,  634. 

etiology  of,  634. 

treatment  of,  636. 
sinus,  625. 
urethra,  625. 
utricle,  625. 

wounds,   dangers   of,   632. 
Prostatitis,  acute,  643. 

diagnosis  of,  656. 

due  to  instrumentation,  236. 

etiology  of,  643. 

in  gonorrhea,   130. 

morbid  anatomy  of,  652. 

prognosis  of,  657. 

symptoms  of,  654. 

treatment  of,  658. 

varieties   of,  648. 
Prostatitis,  acute  suppurative,  650. 

etiology  of,  650. 
chronic,  663. 

etiology  of,  663. 

follicular  or  parenchymatous,  665. 
morbid  anatomy  of,  669. 


Prostatitis,    chronic,    follicular,    symptoms 
of,  667. 
treatment  of,  671. 
varieties  of,   663. 
Prostatorrhea,  637. 
Prostatotomy,  721. 
Pseudohermaphroditism,  100,  516. 
Pseudospermatorrhea,  603. 

varieties  of,  607. 
Ptyalism,  489. 

treatment  of,  490. 
Pyelitis,  clinical  features  of  the  urine  in, 
29. 
surgical,  862. 
etiology  of,  862. 
prognosis  of,  868. 
symptoms  of,  864. 
treatment  of,  869. 
Pyelonephritis,  874. 
etiology  of,  874. 
morbid  anatomy  of,  874. 
tubercular,  886. 
Pyonephrosis,  864. 
causes  of,  867. 
results  of,  865. 
symptoms  of,  865. 
treatment  of,  869. 
Pyuria,  25. 

Renal  cysts,  87.8. 
etiology  of,  878. 
symptoms  of,  882. 
treatment  of,  883. 
disturbance,     relation     of,     to     urethral 

fever,  56. 
inadequacv,  12. 
syphilis,  900. 

symptoms  of,  902. 
treatment  of,  902. 
tuberculosis,  886. 
diagnosis  of,  887. 
forms  of,  886. 
prognosis  of,  888. 
treatment  of,  888. 
Rest  in  genito-urinary  disease,  4. 
Rete  testis,  918. 

Satyriasis,  544. 
causes  of,  544. 
treatment  of,  547. 
Scrotum,  cancer  of  the,  920. 
diseases  of  the,  918. 
eczema  of  the,  918. 

treatment  of,  918. 
elephantiasis  of  the,  920. 
phthiriasis  of  the,  919. 

treatment  of,   919. 
redundancy  of  the,  921. 
Seminal  vesicles,  diseases  of  the,  /28. 

tiiberculosis  and  cancer  of  the,  731. 
Seminal  vesiculitis,  729. 
causes  of,  729. 
diagnosis  of,  730. 
symptoms  of,  729. 
treatment  of,  730. 


1008 


INDEX. 


Septum  pectinifonne,  70. 

Sex,    aben-ant    and    imperfect    ditterentia- 

tions  of,  515. 
Sexual  excess,   561. 
treatment  of,  563. 
function,  regulation  of  the,  7. 

and  instinct,  diseases  of  the,  524. 
instinct,  aberrations  of  the,  529. 
perversion  and  inversion,  529. 
forms  of,  530. 
treatment  of,  542. 
starvation,  6. 
Sexuality,  inverted,  536. 
Skin,   condition  of,   as  influencing  genito- 
urinary and  venereal  diseases,  4. 
Smegma  prseputii,  71. 

Sound,  proper  method  of  introducing,  231. 
Sounds,  metallic,  226. 
Spermatic  congestion,  937. 
cord,  916. 

hematocele  of,  927. 
treatment  of,  927. 
Sjiermatocele,   937. 
diagnosis  of,  938. 
treatment  of,  938. 
true,  937. 
Spermatophobia,  613. 
Spermatorrhea,  602. 

and  pseudospermatorrhea,  tabulated  eti- 
ology of,  608. 
aphrodisiac  drugs  in,  619. 
clinical  features  of  the  urine  in,  31. 
etiology  of,  604. 
prophylaxis  of,  616. 
pseudospermatorrhea,  603. 
special  treatment  of,  616. 
symptomatic,  611. 
symptoms  of,  608. 
treatment  of,  614. 
varieties  of  true,  607. 
Spermaturia,  32. 
Sterility,  568. 

and  impotence  in  the  female,  596. 

etiology  of,  596. 
diagnosis  of,  575. 
etiology  of,  570. 
treatment  of,  575. 
Stone,  selection  of  operation  for.  791. 
vStricture,  benefits  of  gradual  dilation  in, 
56. 
complications  and  results  of,  240. 
congenital,  182. 
congestive,  182. 

or  inflammatory,  181. 
treatment  of,  181. 
of  the  deep  urethra,  treatment  of,  219. 
of  the  male  urethra,  172. 

causes  of,  172. 
of  the  meatus,  treatment  of,  215. 
of  the  penile  urethra,  treatment  of,  215. 
operative  treatment  of,  237. 
organic,  181. 

diagnosis  of,  206. 
etiology  of,  201. 
location  of,   189. 
morbid  anatomy  of,  195. 


Stricture,   organic,   pathologic   localization 
of,  191. 

prognosis  of,  210. 

symptoms  of,  203. 

treatment  of,  213. 

by  systematic  dilation,  224. 

varieties  of,  184. 
spasmodic,  173. 

causes  of,  175. 

chronic,   177. 

location  of,  174. 

treatment  of,  180. 
traumatic,  182. 
urethral,  in  the  female,  183. 
Syphilide,  the  papular,  384. 

tubercular,  417. 
Syphilides,  the,  432. 

physical  characters  of,  432. 

polymorphous,   433. 
Syphilis.  332. 

acquired  immunity  for,  341. 

in  children,  455. 
and  chancroid,  duality  of,  338. 
animal,  342. 

as  a  complication  of  chancroid,  293. 
bacillus  of,  347. 
brain  and  nerve,  early,  o98. 
care  of  the  mouth  in,  507. 
congenital,  455. 

general  characters  of,  466. 

lesions  of,  462. 

methods  of  acquiring,  455. 

prognosis  of.  466. 

treatment  of,  467. 
course  of  the  induration  of,  356. 
curability  of,  437. 
(I'emhlee^  374. 

dietetic  management  of,  508. 
duration  of,  436. 

infection,  394. 
early  ocular,  393. 

treatment  of  nerve  disease  in,  505. 
effect  of,  on  anus,  451. 

bones,  451. 

cerebro-spinal  axis  and  nerves,  451. 

eyes,  451. 

female  sexual  oi'gans,  451. 

fingers  and  toes,  450. 

hair  and  nails,  450. 

larynx,  451. 

liver,  spleen,  and  kidneys,  451. 

male  sexual  organs,  450. 

mucous  membranes,  449. 

nose,  451. 

oro-jiharvnx,  451. 

skin,  449. 

special  structures,  449. 
effects  of  occupation  on,  346. 
evolution     of     primary     lymphitis     and 

adenopathy  in,  353. 
exposure  to  cold  and  wet  in,  508. 
fetal  and  placental  changes  from,  460. 
general  conclusions  regarding,  513. 

infection  of,  376. 

management  of,  507. 
hereditaria  tarda,  461. 


IJfDEX. 


1009 


Syphilis,  history  of,  334. 

hydrotherapy  in,  509. 

hA'podermic    injections    of    mercury    in, 
486. 

in  its  rehrtions  to  general  surgery,  395. 

incubation-period  of,  346. 

infectious  secretions  in,  360. 

influence  of,  on  the  spinal  cord,  422. 

iodin   in,   482. 

lessened  vital  resistance  in,  394. 

local  treatment  of,  498. 
iritis.  503. 

mucous  patches,  502. 
skin-lesions,  500. 
typic   course   of,   from   direct    inocula- 
tion, 359. 

mercurial  inunction  in,  485. 

mercury  in,  469. 

-vapor  baths  in,  485. 

methods  of  acquiring,  363. 

modes  of  contagion  of,  365. 

nerve  and  brain,  later  or  sequelar.  420. 

new  remedies  for,  497. 

of  connectiA'e  tissue,  450. 

of  the  nails,  391. 

osseous,  early  symptoms  of,  393. 

periods  of  retardation  or  apparent  quies- 
cence of,  377. 

pharyngo-faucial  infiltration  in,  383. 

precocious  skin-lesions  of,  391. 

primarv  local  changes  from  infection  of, 
349. 

prognosis  of,  396. 

late   nerve-lesions  of,  423. 

racial  susceptibility  to,  346. 

renal,  900. 

selection  of  mercurials  in,  483. 

sequelar     lesions     of     the     mouth     and 
tongue  in,  445. 

special  mucous  lesions  of,  391. 

speedy  absorption  of  the  infectious  prin- 
"  ciple  of,  340. 

symptomatic   division   of  the   stages   of, 
429. 

synopsis  of  a  typic  case  of,  452. 

the  correction  of  pernicious  ideas  of  the 
duration   and  treatment  of,   508. 

the  initial  lesion  of,  348. 

varieties  of  induration  in,  354. 

relation  of,  to  malignant  disease,  441. 

treatment  of,  469. 

untoward  effects  of  iodin  in,  495. 
the  mercurials  in,  488. 

varieties  of,  340. 

visceral  involvement  in,  392. 

AA'hen  to  begin  treatment  in,  482. 
Syphilitic  alopecia,  389. 

ecthyma,  435. 

fever,  381. 

hemianesthesia,  early.  410. 

hemiplegia,  early,  409. 

infection,  general,  pathology  of,  377. 

prodromes,   381. 

roseola,  379. 

rupia,  435. 

sequels,  trophoneurosis  m,  423. 


SjqDhilitics  and  marriage,  438. 
Svphilization,  275. 
Syphilized  cell,  the.  350. 

migration  of,  351. 

modus  operandi   of,  350. 
Syphilophobia,  512. 


Testicle,  retained,  921. 
results  of,  922. 
treatment   of,   923. 
Testis,  anatomy  of  the,  916. 

and  tunica  vaginalis,  hematocele  of.  924. 
diagnosis  of,  926. 
etiology  of,  924. 
treatment  of,  926. 
varieties  of,  925. 
anomalies  and  congenital  deformities  of 

the,  921. 
clinical  features  of  the  urine  in  injuries 

of  the,  28. 
development  of  the,  937. 
•  ejaculatory  ducts  of  ihe,  918. 
encephaloid  of  the,  979. 

symptoms  and  course   of,  980. 
treatment  of,  981. 
glandular  structure  of  the,  917. 
hypertrophy   and   atrophy   of  tlie.   923. 

'treatment  of,  923. 
malignant  tumors  of  the.  979. 
sarcoma  of  the,  981. 
treatment  of,  982. 
syphilitic  neoplasms  of  the,  969. 
syphiloma  of  the,  970. 
forms  of,  970. 
results  of,  97 1. 
treatment  of,  972. 
table  of  neoplasms  of  the,  983. 
traumatisms  of  the,  924. 

treatment  of,  924. 
tuberculosis  of  the,  973. 
forms  of,  973. 
morbid  anatomy  of,  974. 
symptoms  of,  975. 
treatment  of,  976. 
tumors  of  the,  rarer  forms  of,  983. 
Testes,  916. 
Tissue-metabolism,    perverted,    in    relation 

to  urethral  fever,  58. 
Tobacco,   effect   of.   in    genito-urinary   and 

venereal  diseases,  4. 
Toxemia  from  stricture,  205. 
Toxemias  of  urinary  origin.  46. 
Tuberculosis,  genito-urinary.  clinical  feat- 
ures of  the  urine  in,  32. 
Tunica  albuginea.  917. 
vaginalis  testis,  916. 
vasculosa,   917. 
Tyson,  glands  of,  70. 

Ulcer,  simple,  of  the  penis,  88. 

treatment  of,  89. 
Ui"ea,  17. 
Ureter,  diseases  of  the,  907. 

etiology  of.  907. 
operations  on  the,  908. 


1010 


INDEX. 


Ureters,  anomalies  of  the,  843. 
Urethra,  anatomy  of  the,  94. 
cancer  of  the,  114. 
symptoms  of,   115. 
treatment  of,  11.5. 
clinical  features  of  the  urine  in  iniuries 

of  the,  27. 
congenital  deformities'  of  the,  99. 
curve  of  the,  98. 
foreign  substances  in  the.  111. 
possible  results  of.   111. 
treatment  of,  112. 
injuries  of  the,   110. 
length  of  the,  96. 
membranous,  95. 
physiologic  function  of  the,  94. 
spongy,  95. 
tumors  of  the,  112. 
LTcthral  injuries,  treatment  of.  HI. 

traumatism,  possible  results   of,   110. 
Jrethrismus.   177. 
Urethritis,  116. 
abortive  treatment  of,  I.36. 
acute,  caused  by  instrumentation.  236. 

clinical  features  of  the  urine,  28. 
chronic,   149. 
causes  of,  149. 
duration  of,  152. 
treatment  of,  153. 
varieties  of,  149. 
complications  of,   129. 
etiology  of,  118. 
gonococcic  or  specific,  121. 
exciting  causes  of,   121. 
in    women,    169. 
morbid  anatomy  of,  125. 
period  of  incubation  of,   127. 
simple.  118. 
special    treatment    of    the    complications 

of,  160. 
symptoms  of,  127. 
systematic  treatment  of,  138. 
treatment  of,  134. 
varieties  of,   118. 
7rethrococcus,  123. 
L'rethrometer,  206. 
Urethroplasty,  260. 
Urethrotome,  dilating,  240.- 
Urethrotomes,  239. 

Jrethrotomy,  dilating,  after-effect  in,  242. 
permanence  of  result  in,  243. 
external,  244. 
internal.  239. 

untoward  effects  of,  241. 
Jric  acid,  18. 

Jrinalysis  in  its  surgical  relations,   10. 
Urinary    calculi.    776. 
deposits,  organized,  23. 

rare.  779. 
sediments,  gross  characters  of,  16. 
solids,  proportion  of,  11. 
Jrine,  acidity  of.  influence   of  diet   in   re- 
ducing,  3. 
water  in  reducing,  2. 
bacteria  in,  15. 
character  of,  in  special  conditions,  23. 


Urine,  clinical  features  of,  in  various  dis- 
eases, 27. 
fever,  chronic  form  of,  61. 

typic,   60. 
foam  upon  the,  16.     - 
incontinence  of,  839. 
treatment  of,  840. 
infiltration  of,  251. 

treatment  of,  255. 
macroscopic  study  of  the,  10. 
normal,   1. 
odor  of  the,  14. 
reaction  of  ihe,  14. 

retention  of,  complicating  stricture.  250. 
treatment   of,   251. 
in  urethritis,  130. 
treatment  of,  161. 
specific  gravity  of  the,  13. 
transparency  of  the,  14. 
quantity  of  the,  10. 
Uterus  masculinus,  625. 


Varicocele,  985. 
etiology  of,  986. 
frequency  of.  985. 
location  of.  986. 
morbid  anatomy  of,  989. 
svmptoms  of.  989. 
treatment  of,  990. 
operative,  991. 
palliative,  991. 
^'as  deferens,  916. 
Yasa  eff'erentia,  918. 
Vasculum  aberrans,  937. 
Veru  montanum,  625. 
Vesical  abscess,  754. 
atony.  836. 

etiology  of,  836. 
svm]5toms   of,   836. 
treatment  of,  837. 
calculus.  779. 
cysts,  768. 
growths,  malignant,  762. 

symptoms  of  the  rarer  forms  of.  762. 
hyperesthesia.  830. 
etiology  of,  831. 
svmptoms  of,  832. 
treatment  of.  832. 
and  neuralgia  in  women,  835. 
etiology  of,  835. 
treatment   of,   835. 
inflammation,  acute,  clinical  features  of 

the  urine  in,  28. 
neuralgia,   834. 

treatment  of,  835. 
papilloma.   757. 
diagnosis  of,  759. 
prognosis  of,  760. 
symptoms  of,  758. 
treatment  of,  760. 
paralvsis,  838. 
etiologv  of,  838. 
results"  of,  838. 
treatment  of,   839. 
tuberculosis,  770. 


INDEX. 


101] 


Vesical   tuberculosis,  diagnosis  of,   773. 

morbid  anatomy  of,  772. 

symptoms  of,  772. 

treatment   of,   773. 
tumors,   treatment   of,   7(j4. 
ulcer,  753. 


Vesicles,  seminal,  918. 

Wolffian  body,  937. 
duct,  937. 

Xanthic  acid  in  the  urine,  21. 
Xanthin  in  the  urine,  21. 


P^^;4' 


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